We read with interest the study by Chen and colleagues1 detailing the discrepancies in prescribing rates of antipsychotics in US nursing homes (NHs). This issue has been rendered far from trivial, given the parade of well-publicized articles and Food and Drug Administration warnings about the increased risk of death from antipsychotics in elderly individuals with dementia.2,3 The investigators raise the concern that NH prescribing differences may be rooted primarily in prescribing bias. In our experience as practicing internists and psychiatrists, we are accustomed to the referral bias that occurs among NHs—statistics that are not captured well by Minimum Data Set codes. We routinely find nursing facilities that are more “willing” to accept challenging patients, either those receiving antipsychotics (with no clear indication) or the minority who become highly symptomatic after antipsychotic discontinuation. These facilities often care for complex patients who have received multiple psychotropic medication trials, including antidepressants, sedative hypnotics, and not infrequently, several antipsychotics.
Xiong GL, Raj YP. Variations in Antipsychotic Prescribing in Nursing Homes: Can This Be Reflective of Referral Patterns?. Arch Intern Med. 2010;170(10):917–918. doi:10.1001/archinternmed.2010.143