Twelve Tests and Treatments to Question

by
Canadian Academy of Child and Adolescent Psychiatry
Canadian Academy of Geriatric Psychiatry
Canadian Psychiatric Association

Last updated: September 2023

Original text with references can be found here.

Don’t use SSRIs as the first-line intervention for mild to moderately depressed teens.

Evidence clearly indicates that antidepressant medication is less effective in children and adolescents up to the age of 17 years when compared to treatment in adults, and first-line treatment for this group should include cognitive behavioural therapy or interpersonal psychotherapy. Attention should always be focused on children’s and teens’ environmental safety and adequate parental support to avoid missing cases of neglect, abuse or trauma. Treatment should also include psychoeducation on the importance of regular sleep, diet and exercise to ensure healthy, age-appropriate developmental support.

Don’t use atypical antipsychotics as a first-line intervention for Attention Deficit Hyperactivity Disorder (ADHD) with disruptive behaviour disorders.

Treatment of ADHD that is accompanied by disruptive behaviour disorders should include adequate education of patients and their families, behavioural interventions, psychological treatments and educational accommodations first. If this approach is not sufficient, stimulant medication and a behavioural analysis to ensure appropriate support from the parent and classroom is indicated. The use of alpha 2 agonists (such as guanfacine or clonidine) and atomoxetine should be considered before using atypical antipsychotics (such as risperidone) in children with ADHD and comorbid disruptive behaviour disorders (oppositional defiant disorder, conduct disorder). Although risperidone may provide some short-term reduction in aggression and conduct problems in children, its negative metabolic side effects must be balanced against its potential benefits.

Don’t use psychostimulants as a first-line intervention in preschool children with ADHD.

Preschool children with ADHD need to be assessed for other neurodevelopmental disorders and consideration given to environmental stressors such as neglect, abuse or exposure to domestic violence. Although there is some evidence supporting the use of stimulants among preschoolers with ADHD, treatment should instead start with adequate education and support of parents followed by advice on behavioural management and community placement, given the potential side effects of stimulants in younger ages.

Don’t routinely use antipsychotics to treat primary insomnia in any age group.

Recent research confirms a dramatic increase in the use of atypical antipsychotics with subsequent side-effects including obesity, which is already a major health issue. These drugs carry significant risk of potential side-effects including weight gain and metabolic complications, even at low doses used to treat insomnia. In patients with dementia, they can also potentially cause serious side-effects of increased risk of cerebrovascular event and increased risk of death. It is prudent to pursue nonpharmacological measures first, such as behavioural modifications and ensuring good sleep hygiene (such as eliminating daytime napping and shutting off electronics an hour before bedtime). If these interventions are not successful and with clinician awareness of recent guidelines, medications may be suggested.

Don’t routinely order qualitative toxicology testing (urine drug screen) on all psychiatric patients presenting to the emergency room.

There is no evidence to support ordering routine toxicology testing for all patients presenting to the psychiatry emergency room service. Furthermore, routine testing presents the potential for false positives and false negatives. Lastly, testing may delay psychiatric assessment and management.

Don’t routinely use antidepressants as first-line treatment for mild or subsyndromal depressive symptoms in adults.

Antidepressant response rates are higher for depression of a moderate to severe nature. For mild or subsyndromal depressive symptoms a complete assessment, ongoing support and monitoring, psychosocial interventions and lifestyle modifications should be the first lines of treatment. This may avoid the side-effects of medication and establish etiological factors important to future assessment and management. Antidepressants are appropriate in cases of persistent mild depression, where there is a past history of more severe depression, or where other interventions have failed.

Don’t routinely order brain neuroimaging (CT or MRI) in first episode psychoses in the absence of signs or symptoms suggestive of intracranial pathology.

Signs and symptoms suggestive of intracranial pathology include headaches, nausea and vomiting, seizure-like activity, and later-age of onset of symptoms. Multiple studies have found that routine neuroimaging in first episode psychoses does not yield findings which alter clinical management in a meaningful way. The risks of radiation exposure and delay in treatment also argue against routine neuroimaging. Although a recent meta-analysis supported the use of MRI for all patients with first episode psychosis, the conclusion is controversial, did not review if clinical signs or symptoms of intracranial pathology were present or not, and based the conclusions on MRI abnormalities in 5.9 per cent of first episode psychosis patients, prompting further neuroimaging or referral to neurology for opinion, rather than changes in the management of the psychosis.

Don’t routinely continue benzodiazepines initiated during an acute care hospital admission without a careful review and plan of tapering and discontinuing, ideally prior to hospital discharge.

Benzodiazepines, while helpful for short-term relief of anxiety and insomnia, are associated with a variety of side-effects and long-term problems including cognitive and psychomotor impairment as well as abuse and dependence. Benzodiazepines are commonly used in hospital to treat anxiety or insomnia in association with either the presenting condition or the hospital environment. Once the presenting condition is treated, benzodiazepines should be tapered and discontinued. For patients who are still on benzodiazepines at the time of discharge, a plan for tapering and discontinuing them after discharge should be completed and specified in the discharge summary and prescription.

Don’t 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.

The concurrent management of psychiatric illness and alcohol use disorders requires evaluation of the role alcohol plays as a causative factor for depressive symptoms. Studies have found that response rates to antidepressants are higher when antidepressants are reserved for persistence of symptoms after a period of sobriety lasting from two to four weeks. Additionally, studies have demonstrated remission from depressive symptoms with sobriety in the absence of antidepressant treatment in a significant percentage of cases. Management of comorbid psychiatric illness and substance use disorders including alcohol dependence involves assessment and treatment delivered in a concurrent manner.

Don’t routinely prescribe high-dose or combination antipsychotic treatment strategies in the treatment of schizophrenia.

High-dose and combination strategies involving atypical antipsychotics (AAPs) are used in clinical practice for patients with schizophrenia who are inadequately controlled with one or more AAPs used at standard doses. In terms of safety, no clinically significant differences were evident between combination or high-dose therapy in comparison with standard-dose monotherapy. As distinct from routine treatment, treatment resistant or carefully selected patients with schizophrenia may benefit from prescribing regimens involving cautious polypharmacy. Emerging evidence suggests that particular symptom profiles, such as a preponderance of negative symptoms or antipsychotic-induced hyperprolactinemia may benefit from augmentation with a partial dopamine agonist.

Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia.

People with dementia often exhibit challenging behavioural symptoms such as aggression and psychosis. In such instances, antipsychotic medicines may be necessary, but should be prescribed cautiously as they provide limited benefit and can cause serious harm, including premature death. Use of these drugs should be limited in dementia to cases where nonpharmacologic measures have failed, and where the symptoms either cause significant suffering, distress, and/or pose an imminent threat to the patient or others. A thorough assessment that includes identifying and addressing causes of behaviour change can make use of these medications unnecessary. Epidemiological studies suggest that typical (i.e., first generation) antipsychotics (i.e., haloperidol) are associated with at least the same risk of adverse events. This recommendation does not apply to the treatment of delirium or major mental illnesses such as mood disorders or schizophrenia.

Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia.

Nonpharmacological interventions such as cognitive behavioural therapy and brief behavioural interventions have proven benefit in the management of insomnia in older adults. Epidemiological studies have shown that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Prescribing or discontinuing sedative-hypnotics in hospital can have substantial impact on long-term use. These potential harms and others such as impaired cognition need to be recognized when considering treatment strategies for insomnia. Use of benzodiazepines should be limited to as short a period as possible, in cases where nonpharmacological therapies have failed, and the symptoms of sleep disturbance cause significant suffering or distress.