Tag Archives: Antipsychotics

Caring for older adults: What physicians, patients should question and what reporters should look at

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Liz Seegert

About Liz Seegert

Liz Seegert (@lseegert), AHCJ’s topic leader on aging, is writing blog posts, editing tip sheets and articles and gathering resources to help our members cover the many issues around our aging society. If you have questions or suggestions for future resources on the topic, please send them to liz@healthjournalism.org.

Hospital patient

Photo by dyniss via Flickr

The American Geriatrics Society (AGS) today published the results of its examination of care to determine the top five things patients and physicians should question when caring for older adults. 

  • Recommending percutaneous feeding tubes in patients with advanced dementia; instead of offering oral-assisted feeding.
  • Using antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
  • Using medications to achieve hemoglobin 7.5 percent in most adults age 65 and older; moderate control is generally better.
  • Use of  benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.
  • Use of antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

AGS partnered with the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign to evaluate information from ABIM societies and AGS members. They looked at whether physician-ordered tests and procedures were sufficiently evidence-based, whether the potential health benefits were worth any risks they might pose, if they were redundant or medically necessary. The goal of the campaign is to pinpoint and eliminate unnecessary health spending. Continue reading →

Experts with ties to drugmakers promoted prescribing opiates to older patients

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Judith Graham

About Judith Graham

Judith Graham (@judith_graham), a Colorado-based freelancer, is AHCJ’s topic leader on aging, and as such curates related material at healthjournalism.org. She welcomes questions and suggestions on aging issue resources and tip sheets at judith@healthjournalism.org.

Should older adults use powerful narcotics for ongoing pain relief?

This is a much-debated topic in geriatric circles. Last week, it burst into the public sphere with an article in the Milwaukee Journal Sentinel and MedPage Today by John Fauber and Ellen Gabler.

Their story focuses on a 2009 recommendation by the American Geriatrics Society that physicians consider prescribing opiates more often to seniors with moderate to severe pain.

Potential conflicts of interest may have compromised the Geriatric Society’s guidelines, Fauber and Gabler discovered. Five of 10 panel members who prepared the report had financial ties with opiate drugmakers and a sixth member began serving as a speaker for a drug company in the following year.

In another disturbing finding, Fauber and Gabler reveal that a pain guide endorsed by the Geriatrics Society and funded by an opioid drugmaker highlighted benefits of narcotics while downplaying risks – the potential for addiction, cognitive problems, overdosing, falls and fractures, and the enhancement rather than diminishment of pain.

“None of these side effects was included” in the document; instead, it claimed that “opiods allow people with chronic pain to get back to work, run and play sports,” they write.

The Geriatrics Society told the reporters that it stands behind the guide and is “deeply concerned that public policy may create barriers that will limit older adults’ access to pain medicine.”

In a sidebar, Fauber and Gabler examine a related issue in this controversy: the contention that alternatives to opioids – common over-the-counter drugs such as Aleve, Advil and Motrin – can have more deleterious health effects than narcotics. Continue reading →

NYT series digs into overprescription and developmentally disabled adults

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Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

In the series Abused and Used, New York Times reporter Danny Hakim and a host of his colleagues have been investigating how public resources are used to treat developmentally disabled New Yorkers. The series is ongoing, but hit an inflection point with the publication of Hakim’s piece on the few-strings-attached use of very powerful drugs to treat some of the state’s most vulnerable adult residents.

Developmental disabilities, Hakim writes, often manifest themselves in ways that are easily mistaken for mental illness, and these misdiagnoses can lead to unnecessary or improper medication. “In fact,” Hakim writes, “developmentally disabled residents of group homes in New York are more likely to be given Ativan, an anti-anxiety drug that has a tranquilizing effect, than multivitamins, the records show.”

Hakim’s reporting is rich with both anecdotes and data. These paragraphs from the series will give you an idea of how he approached the issue.

Tens of thousands of powerful pills created to treat serious mental illnesses like schizophrenia are given to developmentally disabled people in the care of New York State every day.

…a review by The Times of previously unreleased records, as well as interviews with state employees, clinicians, family members and outside experts, reveals that the psychotropic medications, which alter the brain’s chemistry, are often dispensed sloppily, without rigorous or regular review, by general practitioners with little expertise in the area.

And low-level workers at state group homes are frequently given discretion to increase the medication “as needed,” despite their lack of significant training.

Psychologists who have worked inside the system describe a culture in which the drugs are used to control the disruptive behavior of the developmentally disabled — people with conditions like autism, Down syndrome and cerebral palsy — an approach increasingly discredited in the field.

Antipsychotic use booms among Canadian kids

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Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

Writing for The Vancouver Sun and Postmedia News, Sharon Kirkey and Pamela Fayerman, report that, in an environment where the rate at which physicians are recommending certain antipsychotics for children has doubled since 2006, a local children’s hospital has launched what the reporters call “the world’s first clinic to help children cope with the side effects of such medications.”

The clinic, which helps children and their parents prepare for antipsychotic use or cope with its side effects, opened in April and has a four-week waiting list.

(Dr. Jana Davidson, a child and adolescent psychiatrist who helped establish the specialized clinic) said she helped create the clinic because of her increasing alarm over the side effects of treatment in her patients. While she believes the medications are sometimes prescribed inappropriately, they are often useful for a range of disorders including severe aggression, mania in bipolar disorder and schizophrenia. But the side effects can be serious.

“I would see kids with psychosis in the emergency department and then I would see them again 10 months later and they would be 30 to 50 pounds heavier,” she said.

Despite sometimes serious neurological side effects, more Canadian families are turning to the drugs and antipsychotic drug recommendations for youth jumped 114 percent in Canada from 2005 to 2009.

The drugs — which have not been approved in Canada for use in children under 18 — are being used for attention-deficit/hyperactivity disorder, conduct disorders, irritability related to autism, mood disorders, physical or verbal aggression and other behavioural problems.

Fla. juvenile justice system relies on heavy antipsychotic use

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Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

In looking into the state Department of Juvenile Justice’s use of powerful prescription antipsychotics, The Palm Beach Post‘s Michael LaForgia “analyzed department drug purchasing information and state Medicaid billing data and reviewed thousands of pages of DJJ inspection reports, drug company disclosure records and court documents.” It shows, as he surfaces with some powerful numbers and equally alarming anecdotes (Part 1, Part 2, Infographic).

…in state-run jails and residential programs, antipsychotics were among the top drugs bought for kids – and they routinely were doled out for reasons that never were approved by federal regulators, a Palm Beach Post investigation has found.

A key concern is that the prescriptions may be driven by their improper use as chemical restraints, or by the hefty speaker (and related) fees being paid from pharmaceutical companies to the most prolific prescription writers. Unfortunately, specifics are hard to come by as most homes are run by private contractors and the state doesn’t have the resources for close monitoring. For this story, the reporters were only able to obtain two years worth of data for 25 jails and three programs – a fraction of the statewide total. Those data still paint what LaForgia calls a “startling story.”

A look at the sheer numbers of drugs purchased … suggests a startling story is unfolding in state homes for wayward kids.

In 2007, for example, DJJ bought more than twice as much Seroquel as ibuprofen. Overall, in 24 months, the department bought 326,081 tablets of Seroquel, Abilify, Risperdal and other antipsychotic drugs for use in state-operated jails and homes for children.

That’s enough to hand out 446 pills a day, seven days a week, for two years in a row, to kids in jails and programs that can hold no more than 2,300 boys and girls on a given day.

More antipsychotics prescribed to foster children

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Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

Need To Know, the PBS newsmagazine, recently took a look at the use of antipsychotics in foster children. Shoshana Guy’s piece opens with an anecdote about one 10-year-old foster child (now adopted) in Texas and expands from there. In nine years as a ward of the state, the boy was prescribed 20 different drugs by nine different doctors. After his adoption, a new, private physician diagnosed him only with ADHD, treatable with a single medication.

Antipsychotics are designed primarily to treat bipolar disorder and schizophrenia, diseases which affect about 3 percent of the population. Yet somehow, they’re the top selling class of drugs in the United States with $14.6 billion in sales in 2009.

Specific numbers on foster children are hard to come by, but the 2010 paper cited in the broadcast, Antipsychotic Medication use in Medicaid Children and Adolescents (48-page PDF), is a good start. Broader forces, such as pharmaceutical marketing and the increasing frequency of mental illness diagnoses for children are at work here, Guy found, but that doesn’t mean that the foster care environment itself isn’t also a factor. It’s a system in which people are frequently looking for ways to “manage” problematic children. Judging by a companion post on Need to Know, this sounds like a story that will develop significantly in the coming year.

…foster care children are prescribed drugs at a rate much greater than that of other kids. Concern over their well-being — not to mention the amount it costs to treat them — has prompted the Government Accountability Office to investigate potentially abusive prescribing practices in America’s state foster care systems. The GAO findings are expected to come out later this year.

Watch the full episode. See more Need To Know.

You can find Need to Know’s health stories on this landing page, but as of yet I haven’t been able to find a health-specific RSS feed.

Some fear DSM update opens door for exploitation

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Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

On All Things Considered, NPR’s Alix Spiegel looks to the past and future to ferret out the potential drawbacks and benefits of the expanded psychiatric diagnoses proposed in the upcoming revision of the American Psychiatric Association’s Diagnostic and Statistical Manual.

dsm-iv

Photo by Richard Masoner via Flickr

Spiegel begins with the forceful perspective of Allen Frances, the man who edited the last update of the DSM. From Frances, Spiegel pulls a few cautionary tales of the unintended consequences of changing DSM entries.

The first? Aspergers.

It’s a disease that needed to be diagnosed, Frances says, but it’s now massively overused because of the unforeseen “unintentional incentive” created by schools that offer greatly expanded educational resources to children diagnosed with Aspergers.

“And so kids who previously might have been considered on the boundary, eccentric, socially shy, but bright and doing well in school would mainstream [into] regular classes,” Frances says. “Now if they get the diagnosis of Asperger’s disorder, [they] get into a special program where they may get $50,000 a year worth of educational services.”

Another cautionary tale? Bipolar disorder. The last DSM revision made it a far easier diagnosis to get. In essence, this easier diagnosis opened a gaping door in medicine, one which pharmaceutical companies quickly muscled through.

“Drug companies got indications for treating bipolar disorder,” Frances says. “Not just with mood stabilizers, but also with the newer antipsychotic drugs. And they began very intensive ubiquitous advertising campaigns. So the rates of bipolar disorder doubled. And lots of people got way too much antipsychotic and mood stabilizing medicines. And these aren’t safe drugs.”

For the other side of the story, Spiegel spoke to a psychiatrist who argued that broadening diagnoses means that fewer of the mentally illl go undiagnosed, and that diagnoses are delivered earlier than they would be otherwise. Furthermore, he believes that adding illnesses to the DSM will spark research and investment toward treating those ilnesses.

Ethics professor takes on clinical trials, marketing

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Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

Writing for Mother Jones, University of Minnesota medical ethics professor Carl Elliott digs into the Dan Markingson story first covered by St. Paul Pioneer Press reporters Jeremy Olson and Paul Tosto. Elliott works at the same institution as the physicians who who administered a Seroquel trial that the 26-year-old was enrolled in when he committed suicide.

Given his teaching field and institution, it’s not surprising that Elliot couldn’t stay away from the Markingson story.

…the more I examined the medical and court records, the more I became convinced that the problem was worse than the Pioneer Press had reported. The danger lies not just in the particular circumstances that led to Dan’s death, but in a system of clinical research that has been thoroughly co-opted by market forces, so that many studies have become little more than covert instruments for promoting drugs. The study in which Dan died starkly illustrates the hazards of market-driven research and the inadequacy of our current oversight system to detect them.

Elliot goes after the idea that the new wave of anti-psychotics was any safer than its predecessors, then explains the clinical trial manipulations he says were used to claim they were.

From there, Elliot takes on the use of clinical trials for marketing purposes. Clinical trials can be dangerous, which is theoretically acceptable if they have the potential to advance medical care. But what if patients are just being exposed to those dangers in an effort to sell more drugs?

Newly released data reveals inappropriate use of antipsychotics in nursing homes

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Pia Christensen

About Pia Christensen

Pia Christensen (@AHCJ_Pia) is the managing editor/online services for AHCJ. She manages the content and development of healthjournalism.org, coordinates social media efforts of AHCJ and assists with the editing and production of association guides, programs and newsletters.

Kay Lazar and Matt Carroll of The Boston Globe have written about nursing homes that use “antipsychotic drugs to control agitation and combative behavior in residents who should not be receiving the powerful sedatives,” a practice that exposes patients to the risk of dangerous side effects.

Their investigation, which included analysis of federal data, found that about “185,000 nursing home residents in the United States received antipsychotics in 2010 contrary to federal nursing home regulators’ recommendations.”

Nursing home regulators have for years collected data about individual homes’ use of antipsychotics but have not publicly released facility-specific information, citing patient privacy concerns. The government finally provided the data to the Globe, 19 months after the newspaper submitted a Freedom of Information Act request.

Part 2 of the project looks at alternatives to sedatives, such as using a circular layout in an Alzheimer’s unit, bringing animals in for contact with residents and learning about patients’ lives before dementia set in so staff can tap into pleasant emotions from the past.

Caring for people with dementia, without relying on antipsychotics, requires nursing home staffers to become detectives, said Paul Raia, vice president of clinical services for the Alzheimer’s Association of Massachusetts and New Hampshire.

Read more about that data here and see the Globe‘s searchable national database that lets users compare nursing homes’ use of antipsychotics.

This graphic shows factors associated with the overuse of antipsychotics.

Medicaid kids more likely to get antipsychotics

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Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

New York Times reporter Duff Wilson reports on federally funded research that has revealed that children covered by Medicaid are four times more likely to get antipsychotic drugs than those covered by private insurers. Wilson puts the story in context with discussion of possible new FDA regulations on antipsychotics for children, as well as state efforts to curb the Medicaid-related prescriptions.

A group of Medicaid medical directors from 16 states, under a project they call Too Many, Too Much, Too Young, has been experimenting with ways to reduce prescriptions of antipsychotic drugs among Medicaid children. They plan to publish a report early next year.

Wilson explores a number of potential causes for the disparity, noting that, at the very least, children on Medicaid don’t get adequate mental health services.