{"id":14796,"date":"2011-10-14T08:30:20","date_gmt":"2011-10-14T12:30:20","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=14796"},"modified":"2011-10-14T15:09:00","modified_gmt":"2011-10-14T19:09:00","slug":"nothing-is-simple-anymore","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/10\/14\/nothing-is-simple-anymore\/","title":{"rendered":"nothing is simple anymore…"},"content":{"rendered":"
I don’t suppose that this report in the American Journal of Psychiatry<\/font><\/strong> comes as any great surprise. It documents the dramatic increase in the use of Atypical Antipsychotics by psychiatrists to treat anxiety over the last decade. But the story of this article is a bit more complicated. I apologize for the length of this post but the puzzle has more than a few pieces. I’ve highlighted the essential pieces in <\/font>red<\/font><\/strong>: <\/div>\n
\n
National Trends in the Antipsychotic Treatment of Psychiatric Outpatients With Anxiety Disorders<\/font><\/strong><\/u><\/a>
by Jonathan S. Comer, Ramin Mojtabai, and Mark Olfson<\/sup>
American Journal of Psychiatry<\/font><\/strong> 2011 168:1057-1065.<\/div>\n

<\/p>\n

Objective<\/font><\/strong><\/u>: The purpose of the present study was to examine patterns and recent trends in the antipsychotic medication treatment of anxiety disorders among visits to office-based psychiatrists in the United States.
Method<\/font><\/strong><\/u>: Annual data from the 1996–2007 National Ambulatory Medical Care Survey were analyzed to examine the patterns and trends in antipsychotic medication treatment within a nationally representative sample of 4,166 visits to office-based psychiatrists in which an anxiety disorder was diagnosed.
Results<\/font><\/strong><\/u>: Across the 12-year period, antipsychotic prescriptions in visits for anxiety disorders increased from 10.6% (1996–1999) to 21.3% (2004–2007). Over the study period, the largest increase in antipsychotic prescribing occurred among new patient visits. Antipsychotic prescribing also significantly increased among privately insured visits and visits in which neither antidepressants nor sedative\/hypnotics were prescribed. Among the common anxiety disorder diagnoses, the largest increase in antipsychotic medication treatment was observed in visits for panic disorder. Antipsychotic prescribing rose from 6.9% (1996–1999) to 14.5% (2004–2007) among visits for anxiety disorders in which there were no co-occurring diagnoses with an indication approved by the Food and Drug Administration for antipsychotic medications.
Conclusions<\/font><\/strong><\/u>: Although little is known about their effectiveness for anxiety disorders, antipsychotic medications are becoming increasingly prescribed to psychiatric outpatients with these disorders.<\/font><\/strong><\/sup><\/div>\n<\/blockquote>\n
<\/div>\n
There’s an accompanying editorial written by Dr. Alan Breier<\/font><\/strong><\/u><\/a> of Indiana University School of Medicine:<\/font><\/div>\n
\n
Anxiety Disorders and Antipsychotic Drugs: A Pressing Need for More Research<\/font><\/strong><\/u>
by Alan Breier, M.D.<\/font><\/strong>
American Journal of Psychiatry<\/font><\/strong> 2011 168:1012-1014<\/font>.<\/div>\n

<\/p>\n

Anxiety disorders are a common, heterogeneous group of illnesses marked by varied clinical presentations, ranging from relatively moderate symptom levels to severe functional impairment and profound disability. Pharmacotherapy, often coupled with behavioral treatments, is a standard approach to treating anxiety disorders. First-line pharmacological treatments for the majority of anxiety disorders are the selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. Sedative-hypnotics are commonly employed for anxiety disorders but are frequently reserved for short durations and targeted symptoms because of the potential for abuse, dependency, withdrawal reactions, and cognitive impairment. The role for antipsychotic drugs in the treatment of anxiety disorders, however, is less clear because of the relative paucity of well-designed trials to assess their safety, efficacy, and effectiveness…<\/p>\n

Another factor that may have contributed to the rise in antipsychotic prescriptions during the time frame of the study’s data collection is widespread and inappropriate marketing practices. While psychiatrists are entitled to use medications for nonapproved conditions such as anxiety disorders, U.S. Food and Drug Administration regulations forbid pharmaceutical companies from promoting the use of medications for nonapproved conditions — yet there is documentation that the marketing of second-generation antipsychotics for nonapproved conditions took place during the period of data collection for this study.<\/font><\/strong><\/p>\n

The use of antipsychotics for anxiety disorders is not approved by the FDA. This point raises a dilemma for clinicians, patients, and payers as to what steps to take when FDA-approved medications fail to deliver adequate clinical outcomes. This scenario is commonly faced in the field of psychopharmacology as prescribers must decide to go off-label and, for example, use higher than approved doses, add combination therapy, or switch to other medications that may not be FDA approved… For clinical conditions for which there are no FDA-approved treatments or for which FDA-approved treatments have failed and there is still a clinical need for treatment, it is incumbent on the academic and clinical fields to provide guidance in the form of expert consensus guidelines and treatment algorithms that are supported by comprehensive reviews of the clinical literature…<\/p>\n

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.<\/font><\/strong> 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.<\/font><\/strong><\/sup><\/div>\n<\/blockquote>\n

With this at the end:<\/div>\n
\n
Footnotes:<\/font><\/strong><\/div>\n