Psychotropic Medication Review: Quo Vadit?

The article by Sheehan et al¹ is a well-crafted systematic review and meta-analysis of 26 studies that examined the effect of psychotropic medication review on the prescribing of several patient populations. This is a carefully constructed article that examines the psychopharmacologic literature for studies that have been sufficiently well controlled to provide credibility of outcome and reviews these outcomes in search of consistent findings across studies. The methodology is sound. The authors are to be commended in their tackling this topic and attempting to make some sense and generalizations about this practice of prescribing review. However, what these investigators have uncovered is the generalization that medication review itself requires a sound evidence base, that is, clinical psychopharmacologists presently must act on the basis of limited data, particularly in some of the populations considered in this study.

The studies examined by Sheehan et al¹ demonstrate that when prescribers are monitored they tend to prescribe less, either in terms of the dosage of medications or in the complexity (polypharmacy) of the number of different medications being prescribed. These changes do not appear to be reflected in cost savings to the patient or to the third-party payer. A more surprising observation appears to be that most of the studies did not show improvement in patient outcomes, and the study by Ballard and colleagues² even suggested clinical deterioration after such review.

The article offers a useful perspective on where this field of prescriber review and analysis stands at the present time. The authors make several observations that bear emphasis. First, while psychotropic medications are typically classified on the basis of their initial indication (eg, antipsychotic, antidepressant, and anxiolytic), they are widely used in contexts such as agitation where efficacy measures are less well standardized. Arriving at such standards may require input from professional organizations, the National Institutes of Health, and the US Food and Drug Administration.

Readers should note the populations chosen for review within the article by Sheehan et al.¹ These populations include elderly people, people with dementia, and adults with intellectual disability. These are populations with a particularly limited database on controlled outcome studies showing benefits from psychopharmacologic prescribing. These are populations with limited algorithms for prescribing to treat target symptoms, often of aggressive or disruptive behaviors, and often symptoms for which the chosen medications being used are off label. New strategies are needed to ensure that these difficult to study populations are not overlooked.

How can such studies be funded? Who are the stakeholders for outcomes of such examinations? Besides the potential benefit to the patient, the third-party payer seems to be the party with the most to gain. If medication load can be lowered without patient harm, there should be a means to calculate the actual savings of such a reduction and compare this with the cost of oversight review and prescriber education. However, to encourage payers to support such investigations there may need to be some proof-of-concept studies to prime the pump. Hopefully, the key stakeholders are reading articles like that by Sheehan et al¹ that point to the need for a next generation of medication review strategies.

While many articles can be valued for the discoveries they make that shape or direct the field of focus, others can have significant merit by uncovering the deficits in our present schema of prescribing and in the limitations of our prescribing knowledge and its application. Here, Sheehan et al¹ shine a spotlight on the tremendous need for a deeper evidence base to inform psychotopic prescribing among otherwise understudied groups.

Published: October 26, 2018. doi:10.1001/jamanetworkopen.2018.3868

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Eichelman B et al. JAMA Network Open.

Corresponding Author: Burr Eichelman, MD, PhD, Department of Psychiatry, University of Wisconsin–Madison, 4711 Sumac Rd, Middleton, WI 53562 (bseichelman@wisc.edu).

Conflict of Interest Disclosures: None reported.