Canadian Psychiatric Association
Association des psychiatres du Canada
Perspective
Choosing Wisely: Wise Choices in Psychiatry
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(11) 700-704 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716643823 TheCJP.ca | LaRCP.ca
Douglas Urness, MD1, Naomi J. Parker, MBA2, Mark J. Rapoport, MD3,4, and Thomas C. R. Wilkes, MD5,6
Keywords Choosing Wisely, low value practice, success chasing Health care is a costly and complex endeavor. In 2011, total Canadian health expenditures were $200.1 billion, or 11.2% of gross domestic product.1 Balancing the financing of health care with quality service delivery is neither simple nor easy. Physicians play a central role in the structure, process, and outcomes of health care and consequently are pivotal to any attempts to improve quality.2,3 While physician practice is primarily focused on quality care and patient outcomes, escalating costs both in absolute dollars and as a percentage of total government spending have directed increasing scrutiny to the value of dollars spent.4 The Institute of Medicine estimates that up to 30% of all health care spending is wasteful.5-7 This estimate of waste and the accountability of the medical profession serve as an important call to action: how much unnecessary treatment exists within health care service delivery systems, and how can we identify and manage it?
Choosing Wisely Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) Foundation, officially launched in 2012 after an extensive planning process.5 It calls for physicians and patients to engage in conversations about what care is truly necessary. The ABIM Foundation states, ‘‘The initial focus [of Choosing Wisely] should be on the overuse of medical resources, which not only is a leading factor in the high level of spending on health care but also places patients at risk of harm.’’6 Choosing Wisely is now an international initiative with a presence in Canada, Australia, the Netherlands, Germany, Japan, and Italy. It uses current evidence combined with expert opinion to inform and challenge practices and interventions that may be unnecessary. Lists of recommendations relating to low value or unnecessary services are forwarded by National Specialty Societies to a National Coordinating Centre and are subsequently made available to both the profession and the public. Recommendations are direct, brief, and typically begin with
‘‘don’t’’ or ‘‘avoid.’’ They are followed by a brief explanation and list of associated references. This method is the result of an extensive planning and design process, which sought to maximize physician uptake and action by appealing to physicians’ sense of professionalism.6,8 The idea of eliminating ‘‘low-value’’ practices is receiving increased research attention. Since 1999, the National Institute for Health and Clinical Excellence (NICE) has identified more than 800 practices that are not effective or good value.9 A recent Australian study reviewed 5209 articles, resulting in 156 health care practices identified and flagged as potentially unsafe, ineffective, or inappropriate in certain circumstances.10 Another study reviewed a decade of literature in high-impact journals to reveal 146 contradicted medical practices; it found reversals for medications, procedures, diagnostic tests, screening tests, and even monitoring and treatment guiding devices. The authors stated that they ‘‘were unable to identify any class of medical practice that did not have some reversal of standard of care.’’11 While psychiatric practice does not easily lend itself to studies that focus on procedural interventions or require objective diagnostic criteria, there is literature suggestive of overuse or misuse of diagnoses and psychotropic mediations. The Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic system is largely based on criteria 1
2
3 4 5 6
Centennial Center for Mental Health and Brain Injury, Alberta Health Services, Ponoka, Alberta Alberta Centre for Child, Family and Community Research, Calgary, Alberta University of Toronto, Toronto, Ontario Sunnybrook Health Sciences Centre, Toronto, Ontario University of Calgary, Calgary, Alberta Alberta Children’s Hospital, Calgary, Alberta
Corresponding Author: Douglas Urness, MD, The Centennial Centre for Mental Health and Brain Injury, Box 1000, Ponoka, Alberta T4J 1R8, Canada. Email: [email protected]
La Revue Canadienne de Psychiatrie 61(11)
requiring subjective interpretation. Some critics claim these criteria are designed to minimize false-negative findings at the expense of increasing false positives with accompanying risks of unnecessary treatment.12,13 Getting specific about recommendations regarding unnecessary investigations and treatment involves identifying clinical scenarios for which there is compelling evidence to guide decision making and evaluating actual service delivery in relation to that evidence. The availability of compelling evidence, associated clinical practice guidelines, and strategies to measure and encourage adherence to guidelines is essential. An extensive literature exists relating to clinical guideline development and knowledge translation and cannot be reviewed here. However, effective practice improvement strategies are likely to require more than simply education and awareness.14 Reminders, interactive education, audit and feedback, and supportive administrative processes have been reported to have greater influence in changing clinical practice patterns.15 There are multiple barriers to practice change and improvement. These include cognitive dissonance resulting from an ingrained, routine pattern of practice coming into conflict with emerging evidence that such practices are unnecessary, wasteful, or potentially harmful. Physicians may be biased by certain belief systems, relationship influences, and deficits in knowledge. These can include a pro-interventional bias from academic training cultures, profit-motivated practices, or fears of omission leading to patient harm and legal recourse. A desire to please patients, referring physicians, and medical product representatives and to maintain social inclusion within established physician groups may also challenge the acceptance of evidence regarding low value but commonly requested interventions.16 Patterns of learning and the tendency to form spurious beliefs in association with confirmation bias also represent a barrier to practice improvement. In a 2011 article, Downar et al.17 described behavioural and neuroimaging findings in physicians responding to a simulated patient encounter involving associative learning. Premature and asymmetrical learning with resulting poor performance was common. Poor performers tended to learn from positive treatment responses (confirmation association) at a much higher rate than from nonresponses (disconfirmation association). High performers tended to learn at smaller but roughly equal rates to either treatment response. Confirmation bias was associated with success chasing, or enthusiastic provision of treatment with hopes for success while neglecting instances of nonresponse. Neuroimaging findings were able to distinguish high performers from low performers based on differential patterns of cerebral activation during the learning task. The authors suggest that awareness of the common pattern of confirmation bias combined with training in disconfirmation learning may improve decision making. This strategy may be particularly relevant to Choosing Wisely and the need to unlearn spurious associations that lead to ineffective practice.
701
Choosing Wisely in Psychiatry Appropriate prescribing practice is the focus for 11 of the 13 Choosing Wisely Canada Psychiatric recommendations. The remaining recommendations relate to neuroimaging and qualitative toxicology testing.18 These recommendations were developed by a working group of the Canadian Psychiatric Association’s (CPA) Professional Standards and Practices Committee with representation from the Canadian Academy of Child and Adolescent Psychiatry, the Canadian Academy of Geriatric Psychiatry, the CPA Member-inTraining Section, and a Canadian Mental Health Association–affiliated person with lived experience. Additional input was received from a CPA member survey, provincial psychiatric association consultations, the Canadian Academy of Psychiatry and the Law, and the Canadian Academy of Psychosomatic Medicine.18 Off-label drug use (OLDU) is relevant to many of the recommendations. OLDU refers to the practice of prescribing a currently approved prescription medication outside the indications set out by the official regulatory bodies. OLDU may involve prescribing a medication for an unapproved indication, at an unapproved dosage, in an unapproved formulation, or in an unapproved population (such as children, pregnant women, or geriatric populations). Psychiatric medications, including antidepressants and antipsychotics, are frequently used for unapproved indications.19 A US study estimated that OLDU for antipsychotics was $6 billion in 2008.20 While OLDU may be appropriate in several situations, such as longstanding and effective practices established before current standards of evidence were established or for effective and rationally supported applications that have not yet received dedicated research attention, its pervasiveness in psychiatry should stimulate consideration about the quality and value of such prescribing. Legal cases in the United States have seen judgments in the billions of dollars levied because of inappropriate promotion of prescribing for unapproved indications.19 In addition to quality of care concerns, the impact of OLDU on costs is important given that expenditures on drugs per capita in Canada are $752 per year, second only to the United States according to a 2013 Organization for Economic Co-operation and Development study of 28 developed countries.1 OLDU has been seen as a potential example of clinical practice influenced by indication creep and a lack of compelling evidence.16 Its pervasiveness in psychiatry should be considered in research agendas and guideline development. Significant increases in psychotropic drug utilization have also stimulated the development of recommendations. Data released by the Canadian Institute for Health Information (CIHI) reported 1 in 12 youth were dispensed psychotropic medication in 2014.21 The same CIHI report found a marked increase of 23% in youth prescribed mood or anxiety medication (largely selective serotonin reuptake inhibitors) and a 45% increase in youth dispensed antipsychotic medication (mostly quetiapine) between 2007-2008 and 2013-2014.21 Available data cannot directly address the appropriateness
702
of these increases in utilization; however, there are suggestions that quetiapine may be used as a long-term sleep aid in the absence of evidence to support this practice. The utilization of psychotropic medication in youth may be influenced by a number of complex contextual factors: recognition of serious mental health disorders, higher rates of emergency department visits and hospitalization, or an overemphasis on pharmacotherapy as a first-line treatment.22 Choosing Wisely Canada recommendations highlight the need for clinicians to be aware of the evidence relevant to prescribing and, where appropriate, consider psychosocial modalities and evidence-based therapies such as cognitive behavioural therapy and family interventions as a first-line approach. Psychotropic prescribing in the older adult population is also a focus of Choosing Wisely Canada recommendations. The practice of antipsychotic prescribing in long-term care settings to individuals with dementia is common,23,24 despite modest benefit and significant risk.25 Similarly, in community settings, benzodiazepines are commonly prescribed26 in the face of significant risk and modest benefit. Choosing Wisely Canada addresses these scenarios. Comorbidity makes evaluation and treatment planning more difficult. Often randomized control trials exclude subjects with comorbidities; however, evidence does exist for some scenarios, which can guide clinicians and form the basis for recommendations. The common clinical scenario of acute psychiatric hospitalization for individuals experiencing significant social stressors, alcohol dependence, depressive symptoms, and suicidal ideation involves treatment decisions including evaluating the use for an antidepressant. Choosing Wisely Canada has released a recommendation stating, ‘‘Do not routinely prescribe antidepressants as first-line treatment for depression comorbid with an active alcohol use disorder without first considering the possibility of a period of sobriety and subsequent reassessment for the persistence of depressive symptoms.’’ This recommendation, which is consistent with the NICE guidelines and multiple literature sources, suggests a period of sobriety, observation, and support before prescribing antidepressants.27 Prescribing antidepressants may be appropriate under certain circumstances, including a history of depression in the absence of alcohol or drug misuse and if the depression clearly developed before alcohol use disorder. The explanation following the recommendation emphasizes the need to concurrently assess and manage the alcohol use disorder and depressive symptoms in a supportive and therapeutic manner. There may be a perception that withholding or delaying a prescription pending sobriety and diagnostic review equates to an absence of care. However, significant rates for remission of depression with supportive care and abstinence from alcohol28 without antidepressants, the lack of compelling evidence for efficacy of antidepressants in this scenario, and recommendations from several guidelines and authors suggest that a supportive, therapeutic, and systembased approach should be considered before prescribing antidepressants.28-33
The Canadian Journal of Psychiatry 61(11)
In addition, the consequences of unnecessary prescribing include a variety of expenses, social consequences, and risks for adverse effects. The time and expense required for physician follow-up visits and medication acquisition are often diverted from resources otherwise directed to family, education, employment, or other personal interests.19 The causative effects of social factors such as working conditions, education, financial status, and social values may be undervalued by perfunctory psychotropic prescribing and simplistic ‘‘blaming the brain’’ for distressing mental states.34 Adverse effects to antidepressants in research studies led to 10% to 20% of patients discontinuing the medication.35,36 While most adverse effects are manageable or temporary, some can be serious.37 Inadvertent drug interactions, such as citalopram with azithromycin causing prolonged QT/QTc intervals, can have fatal consequences.38,39 The consequences of changes to neurotransmitter receptor regulation or dendritic proliferation, both associated with antidepressant use, in the context of prescribing without an approved indication are not fully understood and should promote a sense of caution.40-42 Antidepressant prescribing may lead to a labelling effect or perception of a confirmed genetic risk for depression. In addition, clinical improvements in patients treated with antidepressants before a period of sobriety cannot be relied upon as a predictor of treatment response should similar relapses occur in the future. The potential for these and other untoward consequences of treatment should be balanced against potential benefits as a routine part of clinical assessment and treatment planning. Awareness of this principle is highlighted by the Choosing Wisely initiative, which is designed to appeal to the professionalism of physicians and stimulate their role in improving the quality of health care.
Conclusion In summary, the Choosing Wisely initiative seeks to inform and challenge physicians in their pursuit of higher quality and higher value clinical practice. A significant challenge for Choosing Wisely is implementation: to move beyond ‘‘nice to know’’ and actually change and improve practice. Overcoming barriers will involve multiple approaches, including compelling evidence, systematic reminders, chart audits, administrative support, pursuit of professionalism, high-quality clinical practice guidelines15 indicating what to do instead of what to avoid, and adherence to the first Canadian Medical Association code of ethics principle: ‘‘consider first the wellbeing of the patient.’’43 Acknowledgments This article was written with the support and assistance of the Professional Standards and Practices Committee of the Canadian Psychiatric Association.
La Revue Canadienne de Psychiatrie 61(11)
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Canadian Institute for Health Information. National health expenditures trends, 1975-2013. Ottawa (ON): Canadian Institute for Health Information; 2013. 2. Smith M. Health affairs blog [Internet]. September 6, 2012 [cited 2015 Apr 30]. Available from: healthaffairs.org/blog. 3. Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;260(12):1743-1748. 4. Canadian Institute for Health Information. Health care cost drivers: the facts. Ottawa (ON): Canadian Institute for Health Information; 2011. 5. Choosing Wisely. An initiative of the ABIM Foundation [Internet] [cited 2015 Apr 17]. Available from: www.choosingwisely.org. 6. American Board of Internal Medicine Foundation, American College of Physicians, European Federation of Internal Medicine. Professionalism in the new millennium: a physician charter. Lancet. 2002;359(9305):520-522. 7. Institute of Medicine. Variation in health care: target decision making not geography. Washington (DC): National Academies Press; 2013. 8. Sanmartin C, Murphy K, Choptain N, et al. Appropriateness of healthcare interventions: concepts and scoping of the published literature. Int J Technol Assess Health Care. 2008;24(3): 342-349. 9. Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ. 2011;343:4519-4522. 10. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. MJA. 2012;197(10):556-560. 11. Prasad V, Vandross A, Toomey C, et al. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc. 2013;88(8):790-798. 12. Batstra L, Frances A. Diagnostic inflation: causes and a suggested cure. J Nerv Mental Dis. 2012;200(6):474-479. 13. Paris J. Why is psychiatry prone to fads? Can J Psychiatry. 2013;58(10):560-565. 14. Hailey D, Grimshaw J, Eccles M, et al. Effective dissemination of findings from research—a compilation of essays. Edmonton (AB): Institute of Health Economics; 2008. 15. Koutsavlis AT, Paradis G, Renaud L, Bergeron P. Disseminating practice guidelines to physicians. Montreal (QC): Institut national de sante publique du Quebec; 2001. 16. Scott IA, Elshaug AG. Foregoing low-value care: how much evidence is needed to change beliefs? Intern Med J. 2013; 43(2):107-109.
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17. Downar J, Bhatt M, Montague P. Neural correlates of effective learning in experienced medical decision-makers. PLoS One. 2011;6(11):e27768. 18. Choosing Wisely Canada [Internet] [cited 2016 Jan 13]. Available from: http://www.choosingwiselycanada.org/recommendations/psychiatry/. 19. Wittich CM, Burkle CM, Lanier WL. Ten common questions (and their answers) about off-label drug use. Mayo Clin Proc. 2012;87(10):982-990. 20. Alexander GC, Gallagher SA, Mascola A, Moloney RM, Stafford RS. Increasing off-label use of antipsychotic medications in the United States, 1995-2008. Pharmacoepidemiol Drug Saf. 2011;20(2):177-184. 21. Canadian Institute for Health Information. Care for children and youth with mental disorders. Ottawa (ON): Canadian Institute for Health Information; 2015. 22. Wilkes TCR, Nixon M. Pharmacological treatment of child and adolescent disruptive behaviour disorders: between the Scylla and Charybdis, what do the data say? Can J Psychiatry. 2015; 60(2):39-41. 23. Feng Z, Hirdes JP, Smith TF, et al. Use of physical restraints and antipsychotic medications in nursing home: a crossnational study. Int J Geriatr Psychiatry. 2009;24(10): 1110-1118. 24. Vasudev A, Shariff SZ, Liu K, et al. Trends in psychotropic dispensing among older adults with dementia living in longterm care facilities: 2004-2013. Am J Geriatr Psychiatry. 2015; 23(12):1259-1269. 25. Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14(3):191-210. 26. Mamdani M, Rapoport M, Shulman KI, Herrmann N, Rochon PA. Mental health–related drug utilization among older adults: prevalence, trends, and costs. Am J Geriatr Psychiatry. 2005; 13(10):892-900. 27. National Institute for Health and Care Excellence. Alcohol-use disorders: the NICE guideline on assessment, diagnosis and management of harmful drinking and alcohol dependence. London, UK: The British Psychological Society and The Royal College of Psychiatrists; 2011. 28. McIntosh C, Ritson B. Treating depression complicated by substance misuse. Adv Psychiatr Treat. 2001;7(5):357-364. 29. Nunes EV, Levin FR. Treatment of co-occurring depression and substance dependence: using meta-analysis to guide clinical recommendations. Psychiatry Ann. 2008;38(11): 38-49. 30. Hashimoto E, Tayama M, Ishikawa H, Yamamoto M, Saito T. Influence of comorbid alcohol use disorder on treatment response of depressive patients. J Neural Transm. 2015; 122(2):301-306. 31. Petrakis IL, Gonzalez G, Rosenheck R, Krystal JH. Comorbidity of alcoholism and psychiatric disorders. Alcohol Res Health. 2002;26(2):81-89. 32. Torrens M, Fonseca F, Mateu G, Farre M. Efficacy of antidepressants in substance use disorders with and without comorbid
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33.
34. 35.
36.
37.
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depression: a systematic review and meta-analysis. Drug Alcohol Depend. 2005;78(1):1-22. Shivani R, Goldsmith RJ, Anthenelli RM. Alcoholism and psychiatric disorders—diagnostic challenges. Alcohol Res Health. 2002;26(2):90-98. Moncrieff J. Psychiatric drug promotion and the politics of neoliberalism. Br J Psychiatry. 2006;188(4):301-302. Anderson HD, Pace WD, Libby AM, West DR, Valuck RJ. Rates of 5 common antidepressant side effects among new adult and adolescent cases of depression: a retrospective US claims study. Clin Ther. 2012;34(1):113-124. Canadian Pharmacists Association. CPS: compendium of pharmaceuticals and specialties. Toronto (ON): Canadian Pharmacists Association; 2010. Cascade E, Kalali AH, Kennedy SH. Real-world data on SSRI antidepressant side effects. Psychiatry. 2009;6(2): 16-18.
38. Health Canada. Guidance document—QT/QTc interval prolongation: guidance for product monograph content. Ottawa (ON): Health Canada; 2010. 39. Rabkin SW. Aging effects on QT interval: implications for cardiac safety of antipsychotic drugs. J Geriatr Cardiol. 2014;11:20-25. 40. D’Sa C, Duman RS. Antidepressants and neuroplasticity. Bipolar Disord. 2002;4(3):183-194. 41. Schatzberg AF, Blier P, Delagdo PL, Fava M, Haddad PM, Shelton RC. Antidepressant discontinuation syndrome: consensus panel recommendations for clinical management and additional research. J Clin Psychiatry. 2006;67(4):27-30. 42. Seo MK, Lee CH, Cho HY, et al. Effects of antidepressant drugs on synaptic protein levels of dendritic outgrowth in hippocampal neuronal cultures. Neuropharmacology. 2014;79:222-233. 43. Canadian Medical Association. CMA code of ethics. Ottawa (ON): Canadian Medical Association; 2004.
Association des psychiatres du Canada
Perspective
Choosing Wisely: Wise Choices in Psychiatry
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(11) 700-704 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716643823 TheCJP.ca | LaRCP.ca
Douglas Urness, MD1, Naomi J. Parker, MBA2, Mark J. Rapoport, MD3,4, and Thomas C. R. Wilkes, MD5,6
Keywords Choosing Wisely, low value practice, success chasing Health care is a costly and complex endeavor. In 2011, total Canadian health expenditures were $200.1 billion, or 11.2% of gross domestic product.1 Balancing the financing of health care with quality service delivery is neither simple nor easy. Physicians play a central role in the structure, process, and outcomes of health care and consequently are pivotal to any attempts to improve quality.2,3 While physician practice is primarily focused on quality care and patient outcomes, escalating costs both in absolute dollars and as a percentage of total government spending have directed increasing scrutiny to the value of dollars spent.4 The Institute of Medicine estimates that up to 30% of all health care spending is wasteful.5-7 This estimate of waste and the accountability of the medical profession serve as an important call to action: how much unnecessary treatment exists within health care service delivery systems, and how can we identify and manage it?
Choosing Wisely Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) Foundation, officially launched in 2012 after an extensive planning process.5 It calls for physicians and patients to engage in conversations about what care is truly necessary. The ABIM Foundation states, ‘‘The initial focus [of Choosing Wisely] should be on the overuse of medical resources, which not only is a leading factor in the high level of spending on health care but also places patients at risk of harm.’’6 Choosing Wisely is now an international initiative with a presence in Canada, Australia, the Netherlands, Germany, Japan, and Italy. It uses current evidence combined with expert opinion to inform and challenge practices and interventions that may be unnecessary. Lists of recommendations relating to low value or unnecessary services are forwarded by National Specialty Societies to a National Coordinating Centre and are subsequently made available to both the profession and the public. Recommendations are direct, brief, and typically begin with
‘‘don’t’’ or ‘‘avoid.’’ They are followed by a brief explanation and list of associated references. This method is the result of an extensive planning and design process, which sought to maximize physician uptake and action by appealing to physicians’ sense of professionalism.6,8 The idea of eliminating ‘‘low-value’’ practices is receiving increased research attention. Since 1999, the National Institute for Health and Clinical Excellence (NICE) has identified more than 800 practices that are not effective or good value.9 A recent Australian study reviewed 5209 articles, resulting in 156 health care practices identified and flagged as potentially unsafe, ineffective, or inappropriate in certain circumstances.10 Another study reviewed a decade of literature in high-impact journals to reveal 146 contradicted medical practices; it found reversals for medications, procedures, diagnostic tests, screening tests, and even monitoring and treatment guiding devices. The authors stated that they ‘‘were unable to identify any class of medical practice that did not have some reversal of standard of care.’’11 While psychiatric practice does not easily lend itself to studies that focus on procedural interventions or require objective diagnostic criteria, there is literature suggestive of overuse or misuse of diagnoses and psychotropic mediations. The Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic system is largely based on criteria 1
2
3 4 5 6
Centennial Center for Mental Health and Brain Injury, Alberta Health Services, Ponoka, Alberta Alberta Centre for Child, Family and Community Research, Calgary, Alberta University of Toronto, Toronto, Ontario Sunnybrook Health Sciences Centre, Toronto, Ontario University of Calgary, Calgary, Alberta Alberta Children’s Hospital, Calgary, Alberta
Corresponding Author: Douglas Urness, MD, The Centennial Centre for Mental Health and Brain Injury, Box 1000, Ponoka, Alberta T4J 1R8, Canada. Email: [email protected]
La Revue Canadienne de Psychiatrie 61(11)
requiring subjective interpretation. Some critics claim these criteria are designed to minimize false-negative findings at the expense of increasing false positives with accompanying risks of unnecessary treatment.12,13 Getting specific about recommendations regarding unnecessary investigations and treatment involves identifying clinical scenarios for which there is compelling evidence to guide decision making and evaluating actual service delivery in relation to that evidence. The availability of compelling evidence, associated clinical practice guidelines, and strategies to measure and encourage adherence to guidelines is essential. An extensive literature exists relating to clinical guideline development and knowledge translation and cannot be reviewed here. However, effective practice improvement strategies are likely to require more than simply education and awareness.14 Reminders, interactive education, audit and feedback, and supportive administrative processes have been reported to have greater influence in changing clinical practice patterns.15 There are multiple barriers to practice change and improvement. These include cognitive dissonance resulting from an ingrained, routine pattern of practice coming into conflict with emerging evidence that such practices are unnecessary, wasteful, or potentially harmful. Physicians may be biased by certain belief systems, relationship influences, and deficits in knowledge. These can include a pro-interventional bias from academic training cultures, profit-motivated practices, or fears of omission leading to patient harm and legal recourse. A desire to please patients, referring physicians, and medical product representatives and to maintain social inclusion within established physician groups may also challenge the acceptance of evidence regarding low value but commonly requested interventions.16 Patterns of learning and the tendency to form spurious beliefs in association with confirmation bias also represent a barrier to practice improvement. In a 2011 article, Downar et al.17 described behavioural and neuroimaging findings in physicians responding to a simulated patient encounter involving associative learning. Premature and asymmetrical learning with resulting poor performance was common. Poor performers tended to learn from positive treatment responses (confirmation association) at a much higher rate than from nonresponses (disconfirmation association). High performers tended to learn at smaller but roughly equal rates to either treatment response. Confirmation bias was associated with success chasing, or enthusiastic provision of treatment with hopes for success while neglecting instances of nonresponse. Neuroimaging findings were able to distinguish high performers from low performers based on differential patterns of cerebral activation during the learning task. The authors suggest that awareness of the common pattern of confirmation bias combined with training in disconfirmation learning may improve decision making. This strategy may be particularly relevant to Choosing Wisely and the need to unlearn spurious associations that lead to ineffective practice.
701
Choosing Wisely in Psychiatry Appropriate prescribing practice is the focus for 11 of the 13 Choosing Wisely Canada Psychiatric recommendations. The remaining recommendations relate to neuroimaging and qualitative toxicology testing.18 These recommendations were developed by a working group of the Canadian Psychiatric Association’s (CPA) Professional Standards and Practices Committee with representation from the Canadian Academy of Child and Adolescent Psychiatry, the Canadian Academy of Geriatric Psychiatry, the CPA Member-inTraining Section, and a Canadian Mental Health Association–affiliated person with lived experience. Additional input was received from a CPA member survey, provincial psychiatric association consultations, the Canadian Academy of Psychiatry and the Law, and the Canadian Academy of Psychosomatic Medicine.18 Off-label drug use (OLDU) is relevant to many of the recommendations. OLDU refers to the practice of prescribing a currently approved prescription medication outside the indications set out by the official regulatory bodies. OLDU may involve prescribing a medication for an unapproved indication, at an unapproved dosage, in an unapproved formulation, or in an unapproved population (such as children, pregnant women, or geriatric populations). Psychiatric medications, including antidepressants and antipsychotics, are frequently used for unapproved indications.19 A US study estimated that OLDU for antipsychotics was $6 billion in 2008.20 While OLDU may be appropriate in several situations, such as longstanding and effective practices established before current standards of evidence were established or for effective and rationally supported applications that have not yet received dedicated research attention, its pervasiveness in psychiatry should stimulate consideration about the quality and value of such prescribing. Legal cases in the United States have seen judgments in the billions of dollars levied because of inappropriate promotion of prescribing for unapproved indications.19 In addition to quality of care concerns, the impact of OLDU on costs is important given that expenditures on drugs per capita in Canada are $752 per year, second only to the United States according to a 2013 Organization for Economic Co-operation and Development study of 28 developed countries.1 OLDU has been seen as a potential example of clinical practice influenced by indication creep and a lack of compelling evidence.16 Its pervasiveness in psychiatry should be considered in research agendas and guideline development. Significant increases in psychotropic drug utilization have also stimulated the development of recommendations. Data released by the Canadian Institute for Health Information (CIHI) reported 1 in 12 youth were dispensed psychotropic medication in 2014.21 The same CIHI report found a marked increase of 23% in youth prescribed mood or anxiety medication (largely selective serotonin reuptake inhibitors) and a 45% increase in youth dispensed antipsychotic medication (mostly quetiapine) between 2007-2008 and 2013-2014.21 Available data cannot directly address the appropriateness
702
of these increases in utilization; however, there are suggestions that quetiapine may be used as a long-term sleep aid in the absence of evidence to support this practice. The utilization of psychotropic medication in youth may be influenced by a number of complex contextual factors: recognition of serious mental health disorders, higher rates of emergency department visits and hospitalization, or an overemphasis on pharmacotherapy as a first-line treatment.22 Choosing Wisely Canada recommendations highlight the need for clinicians to be aware of the evidence relevant to prescribing and, where appropriate, consider psychosocial modalities and evidence-based therapies such as cognitive behavioural therapy and family interventions as a first-line approach. Psychotropic prescribing in the older adult population is also a focus of Choosing Wisely Canada recommendations. The practice of antipsychotic prescribing in long-term care settings to individuals with dementia is common,23,24 despite modest benefit and significant risk.25 Similarly, in community settings, benzodiazepines are commonly prescribed26 in the face of significant risk and modest benefit. Choosing Wisely Canada addresses these scenarios. Comorbidity makes evaluation and treatment planning more difficult. Often randomized control trials exclude subjects with comorbidities; however, evidence does exist for some scenarios, which can guide clinicians and form the basis for recommendations. The common clinical scenario of acute psychiatric hospitalization for individuals experiencing significant social stressors, alcohol dependence, depressive symptoms, and suicidal ideation involves treatment decisions including evaluating the use for an antidepressant. Choosing Wisely Canada has released a recommendation stating, ‘‘Do not routinely prescribe antidepressants as first-line treatment for depression comorbid with an active alcohol use disorder without first considering the possibility of a period of sobriety and subsequent reassessment for the persistence of depressive symptoms.’’ This recommendation, which is consistent with the NICE guidelines and multiple literature sources, suggests a period of sobriety, observation, and support before prescribing antidepressants.27 Prescribing antidepressants may be appropriate under certain circumstances, including a history of depression in the absence of alcohol or drug misuse and if the depression clearly developed before alcohol use disorder. The explanation following the recommendation emphasizes the need to concurrently assess and manage the alcohol use disorder and depressive symptoms in a supportive and therapeutic manner. There may be a perception that withholding or delaying a prescription pending sobriety and diagnostic review equates to an absence of care. However, significant rates for remission of depression with supportive care and abstinence from alcohol28 without antidepressants, the lack of compelling evidence for efficacy of antidepressants in this scenario, and recommendations from several guidelines and authors suggest that a supportive, therapeutic, and systembased approach should be considered before prescribing antidepressants.28-33
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In addition, the consequences of unnecessary prescribing include a variety of expenses, social consequences, and risks for adverse effects. The time and expense required for physician follow-up visits and medication acquisition are often diverted from resources otherwise directed to family, education, employment, or other personal interests.19 The causative effects of social factors such as working conditions, education, financial status, and social values may be undervalued by perfunctory psychotropic prescribing and simplistic ‘‘blaming the brain’’ for distressing mental states.34 Adverse effects to antidepressants in research studies led to 10% to 20% of patients discontinuing the medication.35,36 While most adverse effects are manageable or temporary, some can be serious.37 Inadvertent drug interactions, such as citalopram with azithromycin causing prolonged QT/QTc intervals, can have fatal consequences.38,39 The consequences of changes to neurotransmitter receptor regulation or dendritic proliferation, both associated with antidepressant use, in the context of prescribing without an approved indication are not fully understood and should promote a sense of caution.40-42 Antidepressant prescribing may lead to a labelling effect or perception of a confirmed genetic risk for depression. In addition, clinical improvements in patients treated with antidepressants before a period of sobriety cannot be relied upon as a predictor of treatment response should similar relapses occur in the future. The potential for these and other untoward consequences of treatment should be balanced against potential benefits as a routine part of clinical assessment and treatment planning. Awareness of this principle is highlighted by the Choosing Wisely initiative, which is designed to appeal to the professionalism of physicians and stimulate their role in improving the quality of health care.
Conclusion In summary, the Choosing Wisely initiative seeks to inform and challenge physicians in their pursuit of higher quality and higher value clinical practice. A significant challenge for Choosing Wisely is implementation: to move beyond ‘‘nice to know’’ and actually change and improve practice. Overcoming barriers will involve multiple approaches, including compelling evidence, systematic reminders, chart audits, administrative support, pursuit of professionalism, high-quality clinical practice guidelines15 indicating what to do instead of what to avoid, and adherence to the first Canadian Medical Association code of ethics principle: ‘‘consider first the wellbeing of the patient.’’43 Acknowledgments This article was written with the support and assistance of the Professional Standards and Practices Committee of the Canadian Psychiatric Association.
La Revue Canadienne de Psychiatrie 61(11)
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Canadian Institute for Health Information. National health expenditures trends, 1975-2013. Ottawa (ON): Canadian Institute for Health Information; 2013. 2. Smith M. Health affairs blog [Internet]. September 6, 2012 [cited 2015 Apr 30]. Available from: healthaffairs.org/blog. 3. Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;260(12):1743-1748. 4. Canadian Institute for Health Information. Health care cost drivers: the facts. Ottawa (ON): Canadian Institute for Health Information; 2011. 5. Choosing Wisely. An initiative of the ABIM Foundation [Internet] [cited 2015 Apr 17]. Available from: www.choosingwisely.org. 6. American Board of Internal Medicine Foundation, American College of Physicians, European Federation of Internal Medicine. Professionalism in the new millennium: a physician charter. Lancet. 2002;359(9305):520-522. 7. Institute of Medicine. Variation in health care: target decision making not geography. Washington (DC): National Academies Press; 2013. 8. Sanmartin C, Murphy K, Choptain N, et al. Appropriateness of healthcare interventions: concepts and scoping of the published literature. Int J Technol Assess Health Care. 2008;24(3): 342-349. 9. Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ. 2011;343:4519-4522. 10. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. MJA. 2012;197(10):556-560. 11. Prasad V, Vandross A, Toomey C, et al. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc. 2013;88(8):790-798. 12. Batstra L, Frances A. Diagnostic inflation: causes and a suggested cure. J Nerv Mental Dis. 2012;200(6):474-479. 13. Paris J. Why is psychiatry prone to fads? Can J Psychiatry. 2013;58(10):560-565. 14. Hailey D, Grimshaw J, Eccles M, et al. Effective dissemination of findings from research—a compilation of essays. Edmonton (AB): Institute of Health Economics; 2008. 15. Koutsavlis AT, Paradis G, Renaud L, Bergeron P. Disseminating practice guidelines to physicians. Montreal (QC): Institut national de sante publique du Quebec; 2001. 16. Scott IA, Elshaug AG. Foregoing low-value care: how much evidence is needed to change beliefs? Intern Med J. 2013; 43(2):107-109.
703
17. Downar J, Bhatt M, Montague P. Neural correlates of effective learning in experienced medical decision-makers. PLoS One. 2011;6(11):e27768. 18. Choosing Wisely Canada [Internet] [cited 2016 Jan 13]. Available from: http://www.choosingwiselycanada.org/recommendations/psychiatry/. 19. Wittich CM, Burkle CM, Lanier WL. Ten common questions (and their answers) about off-label drug use. Mayo Clin Proc. 2012;87(10):982-990. 20. Alexander GC, Gallagher SA, Mascola A, Moloney RM, Stafford RS. Increasing off-label use of antipsychotic medications in the United States, 1995-2008. Pharmacoepidemiol Drug Saf. 2011;20(2):177-184. 21. Canadian Institute for Health Information. Care for children and youth with mental disorders. Ottawa (ON): Canadian Institute for Health Information; 2015. 22. Wilkes TCR, Nixon M. Pharmacological treatment of child and adolescent disruptive behaviour disorders: between the Scylla and Charybdis, what do the data say? Can J Psychiatry. 2015; 60(2):39-41. 23. Feng Z, Hirdes JP, Smith TF, et al. Use of physical restraints and antipsychotic medications in nursing home: a crossnational study. Int J Geriatr Psychiatry. 2009;24(10): 1110-1118. 24. Vasudev A, Shariff SZ, Liu K, et al. Trends in psychotropic dispensing among older adults with dementia living in longterm care facilities: 2004-2013. Am J Geriatr Psychiatry. 2015; 23(12):1259-1269. 25. Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14(3):191-210. 26. Mamdani M, Rapoport M, Shulman KI, Herrmann N, Rochon PA. Mental health–related drug utilization among older adults: prevalence, trends, and costs. Am J Geriatr Psychiatry. 2005; 13(10):892-900. 27. National Institute for Health and Care Excellence. Alcohol-use disorders: the NICE guideline on assessment, diagnosis and management of harmful drinking and alcohol dependence. London, UK: The British Psychological Society and The Royal College of Psychiatrists; 2011. 28. McIntosh C, Ritson B. Treating depression complicated by substance misuse. Adv Psychiatr Treat. 2001;7(5):357-364. 29. Nunes EV, Levin FR. Treatment of co-occurring depression and substance dependence: using meta-analysis to guide clinical recommendations. Psychiatry Ann. 2008;38(11): 38-49. 30. Hashimoto E, Tayama M, Ishikawa H, Yamamoto M, Saito T. Influence of comorbid alcohol use disorder on treatment response of depressive patients. J Neural Transm. 2015; 122(2):301-306. 31. Petrakis IL, Gonzalez G, Rosenheck R, Krystal JH. Comorbidity of alcoholism and psychiatric disorders. Alcohol Res Health. 2002;26(2):81-89. 32. Torrens M, Fonseca F, Mateu G, Farre M. Efficacy of antidepressants in substance use disorders with and without comorbid
704
33.
34. 35.
36.
37.
The Canadian Journal of Psychiatry 61(11)
depression: a systematic review and meta-analysis. Drug Alcohol Depend. 2005;78(1):1-22. Shivani R, Goldsmith RJ, Anthenelli RM. Alcoholism and psychiatric disorders—diagnostic challenges. Alcohol Res Health. 2002;26(2):90-98. Moncrieff J. Psychiatric drug promotion and the politics of neoliberalism. Br J Psychiatry. 2006;188(4):301-302. Anderson HD, Pace WD, Libby AM, West DR, Valuck RJ. Rates of 5 common antidepressant side effects among new adult and adolescent cases of depression: a retrospective US claims study. Clin Ther. 2012;34(1):113-124. Canadian Pharmacists Association. CPS: compendium of pharmaceuticals and specialties. Toronto (ON): Canadian Pharmacists Association; 2010. Cascade E, Kalali AH, Kennedy SH. Real-world data on SSRI antidepressant side effects. Psychiatry. 2009;6(2): 16-18.
38. Health Canada. Guidance document—QT/QTc interval prolongation: guidance for product monograph content. Ottawa (ON): Health Canada; 2010. 39. Rabkin SW. Aging effects on QT interval: implications for cardiac safety of antipsychotic drugs. J Geriatr Cardiol. 2014;11:20-25. 40. D’Sa C, Duman RS. Antidepressants and neuroplasticity. Bipolar Disord. 2002;4(3):183-194. 41. Schatzberg AF, Blier P, Delagdo PL, Fava M, Haddad PM, Shelton RC. Antidepressant discontinuation syndrome: consensus panel recommendations for clinical management and additional research. J Clin Psychiatry. 2006;67(4):27-30. 42. Seo MK, Lee CH, Cho HY, et al. Effects of antidepressant drugs on synaptic protein levels of dendritic outgrowth in hippocampal neuronal cultures. Neuropharmacology. 2014;79:222-233. 43. Canadian Medical Association. CMA code of ethics. Ottawa (ON): Canadian Medical Association; 2004.
