Controversy over use of antipsychotic drugs for dementia

Antipsychotic drugs are approved mainly for treating schizophrenia and bipolar disorder, but they are also used for many other purposes.

One of the most controversial is reducing disruptive behavior among elderly people with dementia. In the last few years, the FDA has required drug labels to carry warnings regarding this still-common practice, and studies continue to raise questions about its risks and benefits, reports the August 2007 issue of the Harvard Mental Health Letter.

Concern about this issue is not new. A federal law passed in 1987 provides that residents in facilities receiving government support should not receive antipsychotics for problems that are simply inconvenient for caregivers—such as wandering, insomnia, or uncooperativeness—but only for agitated, aggressive, or psychotic behavior that is distressing to the patients or dangerous to others. But the guidelines have not prevented continued heavy use in institutions for the elderly.

There is some evidence that the drugs can help. A review of 16 studies found that some antipsychotics might reduce agitation, aggression, and psychosis, although there was little evidence about long-term use. But for many, the risks outweigh the benefits. The drugs may cause tremors, drowsiness, and weight gain, and they may raise the risk for high cholesterol, diabetes, and heart arrhythmias.

Despite disappointing research findings, clinicians have not given up on the use of antipsychotic drugs for dementia. Dr. Michael Miller, editor in chief of the Harvard Mental Health Letter notes, “If drug use is necessary, it makes sense to start at a low dose and gradually increase it. The need to continue the drug should be evaluated regularly.” Clinicians are advised to document their reasons for prescribing the drug and their understanding of the risks and benefits.

Also in this issue:

• Rethinking post-traumatic stress disorder
• Psychotherapy for bipolar disorder
• Psychological vs. physical pain
• “Clock” gene and bipolar disorder

The Harvard Mental Health Letter is available from Harvard Health Publications, the publishing division of Harvard Medical School, for $59 per year. Subscribe at http://www.health.harvard.edu/mental or by calling 1-877-649-9457 (toll free).