Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Wednesday, November 13, 2013

Choose Wisely, Indeed

There are two health PR campaigns taking place in New York City right now. You see signs on bus stops, in the subway, etc.

One is the NYC Girls Project, with the tag line: I'm a girl and I'm beautiful the way I am. It's directed mainly at girls, ages 7-12, who risk developing negative body images that can lead to eating disorders, drinking, drugs, acting out sexually, suicide, and bullying. It's a well-meaning program, certainly.

Then there's Bloomberg's Combat Obesity project, with ads about too many sugary drinks, reducing portion size, exercising more.

Some would say that these two are at odds with each other. "I'm a girl and I'm beautiful the way I am, except that I need to lose some weight."

It doesn't quite work.

Choosing Wisely is an initiative of the ABIM (American Board of Internal Medicine) Foundation, which tries to encourage patients to make evidenced based choices with their physicians. To this end,  Choosing Wisely asks "national organizations representing medical specialists... to “choose wisely” by identifying five tests or procedures commonly used in their field, whose necessity should be questioned and discussed."

On September 20, 2013, the APA released its Choosing Wisely list:

1. Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.
2. Don’t routinely prescribe two or more antipsychotic medications concurrently.
3. Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
4. Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.
5. Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

I could, of course, be completely scathing and give you my own, sarcastic version:

1. Take a good history and follow up with your patients.
2. Keep a list of what you've already prescribed.
3. There's a reason Janssen Pharmaceuticals is coughing up $2.2 billion.
4. Clozaril doesn't just make you drowsy.
5. We're trying to combat, not create obesity in children.

The truth is, #5 really upsets me. Well, they all do, but #5 most of all. There's an inherent conflict of interest. 

According to npr.org, which does not lie, "Since the mid-1990s, the number of children diagnosed with bipolar disorder has increased a staggering 4,000 percent." Now why is that, DSM, published by APA? 

And people suffering from bipolar disorder sometimes get psychotic, no? And many antipsychotics are FDA approved for the treatment of bipolar disorder, correct?


(Don't' forget Lurasidone (Latuda), now approved for bipolar depression, as well.)

Leaving aside Bipolar disorder, and schizophrenia, there are so many children being prescribed atypical antipsychotics for everything from ADHD to depression to behavioral problems, that all this Choosing Wisely stuff is too little too late.

It doesn't quite work, does it.

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