Choosing Wisely Psychiatry s Top Priorities for Appropriate Primary Care

Transcription

1 Choosing Wisely Psychiatry s Top Priorities for Appropriate Primary Care JASON BEAMAN D.O., M.S., FAPA ASSISTANT CLINICAL PROFESSOR CHAIR, DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL SCIENCES OKLAHOMA STATE UNIVERSITY Board Certified: Forensic Psychiatry Psychiatry Family Medicine

2 Objectives Understand the history and background of Choosing Wisely Understand the 5 APA Choosing Wisely Points Understand the basis of the 5 APA Choosing Wisely Points

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4 About the Campaign An initiative of the American Board of Internal Medicine Foundation Started in 2012 Intended to provide the foundation of a conversation between physician and patient

5 About the Campaign Intent is to prevent the overuse of tests and procedures Engages the patient to make smart and effective care choices Involves leading healthcare organizations and Consumer Reports

6 About the Campaign Choosing Wisely is part of a multi-year effort of the ABIM Foundation to help physicians and other health care providers be better stewards of finite health care resources.

7 About the Campaign Each organization provides a brief list of Things to Question This list addresses common misconceptions and poor practice habits related to that organization Each item is a specific evidence based recommendation

8 Analyzing Things to Question Start with the Organization Each physician should be aware of their own organizations recommendations Each physician should be aware of the organizations that may be applicable

9 Organizations

10 Analyzing Things to Question Look at the Recommendation Short one sentence Very specific

11 Analyzing Things to Question Read the explanation Look at the sources

12 Example-Recommendation Don t prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable.

13 Example-Reasoning The observation option refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. The decision to observe or treat is based on the child s age, diagnostic certainty and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child.

14 Sources Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, Joffe MD, Miller DT, Rosenfeld RM, Sevilla XD, Schwartz RH, Thomas PA, Tunkel DE, American Academy of Pediatrics, American Academy of Family Physicians. The diagnosis and management of acute otitis media. Pediatrics Mar;131(3):e Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev Jan 31;1:CD

15 Exclusion These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

16 American Psychiatric Association Founded in ,500 members More than 100 countries

17 American Psychiatric Association

18 #1 Don t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

19 #1 Metabolic, neuromuscular and cardiovascular side effects are common in patients receiving antipsychotic medications for any indication, so thorough initial evaluation to ensure that their use is clinically warranted, and ongoing monitoring to ensure that side effects are identified, are essential.

20 #1 Appropriate initial evaluation includes the following: a) Thorough assessment of possible underlying causes of target symptoms including general medical, psychiatric, environmental or psychosocial problems b) Consideration of general medical conditions c) Assessment of family history of general medical conditions, especially of metabolic and cardiovascular disorders

21 #1 Appropriate ongoing monitoring includes: a) Re-evaluation and documentation of dose, efficacy and adverse effects b) Assessment of movement disorder or neurological symptoms c) Assessment of metabolic measurements: a) weight, waist circumference and/or BMI b) blood pressure c) heart rate d) blood glucose level e) lipid profile at periodic intervals

22 #1 Re-evaluation and documentation of dose, efficacy and adverse effects: Need to check status of the condition Constantly need to ensure that benefits outweigh the risk *To prescribe antipsychotics without follow-up and re-evaluation is irresponsible and below the standard of care

23 #1 Assessment of movement disorder or neurological symptoms All antipsychotics carry a risk of neurological conditions: Tardive Dyskinesia Dystonia Akesthesia Monitor Tardive Dyskinesia with AIMS

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25 AIMS

26 AIMS

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28 #1 Assessment of metabolic measurements Patients with schizophrenia are at increased risk of Metabolic Syndrome, CAD and Diabetes Antipsychotics increases this risk From , % of all Diabetes was attributed to the use of atypical antipsychotics

29 #2 Don t routinely prescribe two or more antipsychotic medications concurrently.

30 #2 Research shows that use of two or more antipsychotic medications occurs in 4 to 35% of outpatients and 30 to 50% of inpatients. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance and medication errors is increased.

31 #2 Generally, the use of two or more antipsychotic medications concurrently should be avoided except in cases of three failed trials of monotherapy, which included one failed trial of Clozapine where possible, or where a second antipsychotic medication is added with a plan to cross-taper to monotherapy.

32 #2 Essentially you get all the risks with no benefits Be vigilant at times when there are multiple physicians Be vigilant at times of transition of care Stresses the importance of medication reconciliation

33 #3 Don t routinely use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia

34 #3 Behavioral and psychological symptoms of dementia are defined as the non-cognitive symptoms and behaviors, including agitation or aggression, anxiety, irritability, depression, apathy and psychosis. Evidence shows that risks (e.g., cerebrovascular effects, mortality, parkinsonism or extrapyramidal signs, sedation, confusion and other cognitive disturbances, and increased body weight) tend to outweigh the potential benefits of antipsychotic medications in this population.

35 #3 Clinicians should generally limit the use of antipsychotic medications to cases where non-pharmacologic measures have failed and the patients symptoms may create a threat to themselves or others. This item is also included in the American Geriatric Society s list of recommendations for Choosing Wisely.

36 APA Things To Question #3

37 #3 Not a clear pharmacologic mechanism for action for antipsychotics in dementia Demonstrated harm Can have some beneficial properties Very important to discuss risk/benefits with decision maker and document such

38 #4 Don t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

39 #4 There is inadequate evidence for the efficacy of antipsychotic medications to treat insomnia (primary or due to another psychiatric or medical condition), with the few studies that do exist showing mixed results

40 #4 But I ve tried everything else But it works for me Its ok because it s a low dose

41 Medications used to treat sleep

42 #4 There are A LOT of options that are much more effective and have much less side effects than antipsychotics when used for sleep The default of the body and mind is to sleep If not occurring, then regular medicine needs to happen diagnosis Should not routinely use sleep meds long term without workup and evaluation

43 #5 Don t routinely prescribe an antipsychotic medication to treat behavioral and emotional symptoms of childhood mental disorders in the absence of approved or evidence supported indications.

44 #5 There are both on and off label clinical indications for antipsychotic use in children and adolescents. FDA approved and/or evidence supported indications for antipsychotic medications in children and adolescents include psychotic disorders, bipolar disorder, tic disorders, and severe irritability in children with autism spectrum disorders; there is increasing evidence that antipsychotic medication may be useful for some disruptive behavior disorders.

45 #5 Children and adolescents should be prescribed antipsychotic medications only after having had a careful diagnostic assessment with attention to comorbid medical conditions and a review of the patient s prior treatments. Efforts should be made to combine both evidence-based pharmacological and psychosocial interventions and support. Limited availability of evidence based psychosocial interventions may make it difficult for every child to receive this ideal combination.

46 #5 Discussion of potential risks and benefits of medication treatment with the child and their guardian is critical. A short and long term treatment and monitoring plan to assess outcome, side effects, metabolic status and discontinuation, if appropriate, is also critical. The evidence base for use of atypical antipsychotics in preschool and younger children is limited and therefore further caution is warranted in prescribing in this population.

47 #5 The physician prescribing this serious medication to children needs to be on solid ground: Must have accurate diagnosis Must monitor at adult recommendations Must document informed consent with parents

48 #5 A child suspected of having a psychotic or bipolar disorder should be evaluated by a Child and Adolescent Psychiatrist A child with behavior problems needs a serious discussion about behavior modification

49 Summary 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 routinely 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 an antipsychotic medication to treat behavioral and emotional symptoms of childhood mental disorders in the absence of approved or evidence supported indications.

50 Questions?