Continuing the Conversation about Choosing Wisely: The American Psychiatric Association Releases List of Five Uses of Psychiatric Medication to Question


Joel Yager, MD,

Professor, University of Colorado School of Medicine

Chair of the APA Council on Quality Care


Recently the APA released a list of “Five Things Physicians and Patients Should Question” in Psychiatry as part of the Choosing Wisely® campaign, led by the ABIM Foundation. The list identifies five specific evidence-based recommendations that can help physicians and patients make wise choices about their care.


The APA list contains the following five recommendations:

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

Why was this list created?

This list was created to help clinicians and patients reduce the number of times that certain medications are routinely prescribed in situations where other initial treatments might be preferable, and where risks of these medications’ harmful side effects could be decreased or avoided.


Does this list apply to the care of children or adolescents?

For any indication and for any patient, the potential harms of treatment must be weighed against the potential benefits. For the Choosing Wisely campaign, the APA recognizes that for some young patients in some circumstances an antipsychotic medication may turn out to be an appropriate choice of treatment if the clinical benefits are judged to outweigh potential harms after the patient receives appropriate initial evaluation and will receive ongoing monitoring. However, the APA advises physicians and patients to question the routine use of antipsychotic medications in children and adolescents for clinical circumstances where these medications are not endorsed by available clinical practice guidelines or lack explicit FDA approval indications for their use.


Why the Choosing Wisely Campaign?

The facts driving the Choosing Wisely effort are well known: Current health care practices in America spend too much money on unnecessary tests and procedures that do not benefit patients and that may even cause unintended harm. According to a report from the Institute of Medicine, up to 30 percent of health care delivered in the United States is wasteful. Providers and economists agree that these costly unnecessary practices threaten America’s ability to provide the highest quality of care possible to all patients.


Through the Choosing Wisely campaign and by publishing this list, the APA hopes to spark conversations between its members and patients about whether certain tests and treatments are really necessary or the best ones to choose. The APA joined the campaign because it recognizes that physicians have professional, moral and ethical responsibilities to take the lead in addressing these challenges.


While the APA has taken a bold step in identifying and developing the list, our work doesn’t stop here. Over the coming months and years, the APA will be working with the ABIM Foundation, Consumer Reports, and a variety of other Choosing Wiselycampaign stakeholders to raise awareness of these lists and to make them available to patients and the public at large.


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