An interesting thing has been happening in Canada. In late 2011, the British Columbia Ministry of Health issued a report entitled, “A Review of the Use of Antipsychotic Drugs in British Columbia Residential Care Facilities.” The family of a senior living in such a facility raised the issue of over-medication and, instead of reacting defensively, the provincial government set about studying the prescribing practices of physicians in these residential programs.
The review turned up a not too surprising but still startling set of statistics. The use of antipsychotics had increased from 37% of seniors in residential care facilities who were on these medications in 2001-2002, to over 50% in 2011. These data were consistent with studies throughout Canada.The report noted that seniors and their families were not generally well-informed about the benefits and risks of using antipsychotics with a frail and vulnerable population. Virtually all of these individuals have complex physical health care problems and often present behavioral challenges in their facilities. Fifty percent of nursing staff reported being physically assaulted during their attempts to care for the nursing home residents. So there is clearly a need for some intervention and support for staff working in residential care facilities. Whether antipsychotic medications are really the primary answer is one of the key questions raised in the review along with the need for improved family and individual consent to the use of antipsychotic drugs. The Ministry of Health recognized the risk to providers but also pointed out that drugs can also be used as an inappropriate form of restraint.
These concerns have prompted many Canadians who are either seniors already or are moving into that fastest growing population group to consider using advance directives now in order to stave off the likelihood of overmedication if they become disabled enough to need residential care.
To the credit of the British Columbia Care Providers Association (BCCPA), the organization developed a Best Practices Guide to assist their member facilities to recognize the safe and appropriate use of antipsychotic medications and the need to better educate their providers and families about the risks and benefits of the medications. The guide includes a section on safe ways to reduce the use of antipsychotics with seniors in residential care facilities.
It seems there are several lessons to be learned.
In the United States, far too often state and local governments, if they are even aware of the risks of overmedication (which is a problem in and of itself) react defensively to any questioning of current practices. Some of this is undoubtedly a result of fear of litigation if problems are identified and publicized. Some of it has to do with a lack of informed leadership, especially when it comes to the entire area of overuse of psychiatric medications. In addition, many states, including Oregon, have a “carve out” of financial responsibility for psychiatric medications because of the political clout of the pharmaceutical industry so that providers are at no financial risk for what is actually a fairly expensive medical service. Estimates of the cost of psychiatric medications range as high as 50% of the cost of the services themselves. Just one concrete example—a psychiatrist who was identified by Iowa Senator Charles Grassley using Medicaid drug data, in just one year had prescribed nearly $500,000 worth of atypical antipsychotic medications—to children and adolescents. That state’s Medicaid pharmacist reviewed the situation and denied that there was a problem. This does not resemble the Canadian response to the problem they identified with seniors.
We should hope that more state and local governments as well as provider organizations can have the knowledge and the courage to review these issues–and not just for their seniors. Other vulnerable groups include children, especially in (though not limited to) foster care; young adults experiencing a first psychotic episode; and adults who are diagnosed with major mental health challenges. The long-term studies clearly suggest that, while some individuals require ongoing antipsychotic drugs, many can regain their functioning by careful review of the amount and duration of their medication usage.
We need only to look north for a positive example of how to improve care with education and improved guidelines for the use of antipsychotic medications.