Occam’s razor, also known as Ockham’s razor, and sometimes expressed in Latin as lex parsimoniae [the law of parsimony, economy or succinctness], is a principle that generally recommends selecting from among competing hypotheses the one that makes the fewest new assumptions.
I’d like to return for a moment to the recent article in the American Journal of Psychiatry reporting an increase in the prescription of Atypical Antipsychotics for Anxiety Disorders over the last decade and the accompanying editorial [nothing is simple anymore…, at least…].
National Trends in the Antipsychotic Treatment of Psychiatric Outpatients With Anxiety Disorders
by Jonathan S. Comer, Ramin Mojtabai, and Mark Olfson
American Journal of Psychiatry 2011 168:1057-1065.Conclusions: Although little is known about their effectiveness for anxiety disorders, antipsychotic medications are becoming increasingly prescribed to psychiatric outpatients with these disorders.
The authors devote 1500 words to a discussion of their findings, concluding with:
Although our analyses offer little insight into clinical decision making at the individual patient level, the observed antipsychotic prescribing trends appear to reflect a shift in the balancing of risks versus compelling clinical need in office-based psychiatry. Despite limited controlled data for several common anxiety disorders and emerging safety concerns, prescribing patterns suggest a growing acceptance of antipsychotics in the outpatient psychiatric treatment of common anxiety disorders. With increased antipsychotic use, there will be increased need for metabolic monitoring, especially in patient populations with known risk factors for diabetes and cardiovascular disease. Prudence further suggests that renewed clinical efforts should be made to limit use of these medications to clearly justifiable circumstances. At the same time, a new generation of research is needed to assess the efficacy and safety of antipsychotic regimens for anxiety disorders, especially in patients who have not responded to other treatments.
The infuriating companion editorial [Anxiety Disorders and Antipsychotic Drugs: A Pressing Need for More Research] took only 1100 words to conclude:
Perhaps the greatest value of the Comer et al. study is that it calls attention to the pressing need for more research to evaluate antipsychotics for use in patients with anxiety disorders given the high and growing use of these agents in this patient group. We need both well-controlled randomized clinical trials that evaluate the safety and efficacy of antipsychotics for anxiety disorders and large-scale effectiveness studies that determine outcomes in real-world practice settings. Key questions include the following: Do antipsychotics, either as monotherapy or in combination with first-line agents, provide a favorable safety/efficacy profile for anxiety disorders? Is there a unique role for low-dosage antipsychotics in the treatment of anxiety disorders? Do the second-generation antipsychotics that have the most favorable safety profile (the lowest rates of weight gain, metabolic complications, and motor side effects) offer clinical advantages compared with other antipsychotics for patients suffering from anxiety disorders? What treatment approaches are most effective for treatment-refractory anxiety disorders? Given the heterogeneity of anxiety disorders, which individual disorders and symptom complexes, if any, are best suited for antipsychotic therapy? Once the clinical trial database of antipsychotics for anxiety disorders is enriched, clinicians will be able to make rational, evidenced-based decisions about their clinical use for this important group of disorders.
If you don’t know why I call that editorial infuriating, please refer to these posts explaining the reasons in detail [nothing is simple anymore…, at least…].
Dr. Breier’s stealth aside, there’s a much simpler explanation for Dr. Comer’s findings of a dramatic increase in the use of Atypical Antipsychotics to treat Anxiety, requiring no further research. The simplest version of the wisdom of Occam’s Razor is: The simplest explanation is usually right. So my answer to the question, "Why are psychiatrists giving Atypical Antipsychotics to people with Anxiety Disorders?" takes only 9 words. "In Modern Times, they are the only available option."
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• DSM-III, DSM-III R, DSM-IV, DSM-IV TR:
Prior to the DSM-III in 1980, Anxiety was a symptom – fear from an unknown cause – following the psychoanalytic idea that Anxiety was a felt signal of danger. With the coming of the new classification, excessive Anxiety became a Disorder – the problem itself rather than a symptom of the problem. My own take on this change is that this is an area where the DSM revisions were helpful in focusing our attention on those patients whose anxiety transcends their life situation or internal life. The downside of the revision is that it only fits some patients. There are plenty of people whose Anxiety is a symptom of something else – real or imagined.
• Managed Care:
In the 1980s, in response to the general feeling that psychotherapy was being over-used and that Psychiatrists specifically were too expensive, there was a radical change in mental health initiated by the third party carriers. The net result was that covered psychiatric visits were limited in length and number, with reimbursed psychotherapy partitioned to other specialties on a limited basis. The net result was that psychiatrists see patients for brief diagnostic evaluations and medication treatment. That is the current standard of practice.
• Addiction to Benzodiazepines:
The first-line effective pharmaceutical treatment of anxiety are the Benzodiazepines. They are both psychologically and physically addicting. Used long term, tolerance develops and the dose requirement escalates. Standard practice these days is to reserve their use for short term situations and avoid them as maintenance for anxious patients.
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