MAHA and "Psychiatric Overprescribing"

[SchoolPsycho]

Advertisement - Members don't see this ad

Health and Human Services has launched an action plan to, as they put it, curb psychiatric over prescribing. You can see the media release here, and a dear colleague letter with more detail here.

I don't personally perceive this administration as being particularly good at following through on things. But do you see any of this having a tangible impact on patients or the field?

 

[WisNeuro]

No. IME with referral sources and past working in the hospital, it wasn't that patients weren't being recommended psychotherapy, it's that they were, and instead insisted on medication management. Plus, far from the biggest issue in my clinical populations. I'd love to see polypharmacy better dealt with it my 60+ patients, but this will do none of that. Another meaningless press release from a dysfunctional admin that could care less about actually improving health outcomes.

 

[Sanman]

Agreed that many folks want the easy path. A simple approach to this that I am sure this admin will not pursue is strengthening requirements around GDRs. That said, unless you change the reasons behind lack of engagement in psychotherapy (money, time), it is a lot like recommending diet and exercise vs ozempic. Most everyone knows it is a good idea and relatively fewer engage in it.

 

[PsyDr]

When a heroin addict says that he is mentally incompetent, I tend to believe him.

 

[cara susanna]

I was wondering if it will impact federal mental healthcare employees like, y'know, us VA folk

 

[Doctor Eliza]

Best online comment I saw was, “If they want to take away my antidepressants, I’m gonna need a new administration.”

 

[futureapppsy2]

Psychiatric over-prescribing can definitely be an issue (e.g., someone on multiple antidepressants and antipsychotics when they really need DBT more than anything), but do I trust this administration to address it in an evidence-based way that benefits patients? No.

 

[Therapist4Chnge]

No. IME with referral sources and past working in the hospital, it wasn't that patients weren't being recommended psychotherapy, it's that they were, and instead insisted on medication management. Plus, far from the biggest issue in my clinical populations. I'd love to see polypharmacy better dealt with it my 60+ patients, but this will do none of that. Another meaningless press release from a dysfunctional admin that could care less about actually improving health outcomes.

Try taking away “grandma’s little helper” (benzo) and you’ll get knitting needles to the eye or worse.

 

[WisNeuro]

Try taking away “grandma’s little helper” (benzo) and you’ll get knitting needles to the eye or worse.

I will say, at least here, the benzo use in the elderly has dropped a good amount in the past decade. Now if we could just make the same progress with multiple heavy anticholibergics...

 

[cara susanna]

I will say, at least here, the benzo use in the elderly has dropped a good amount in the past decade. Now if we could just make the same progress with multiple heavy anticholibergics...

Which ones, specifically? Benedryl?

 

[WisNeuro]

Which ones, specifically? Benedryl?

Diphenhydramine (so many older folks taking Tylenol PM), oxybutynin, quetiapine, the triptylines, hydroxyzine, paroxetine, and many others. The big issue is that they are additive in nature, so even if you take a handful of milder ones, we still generally see negative cognitive side effects, which tend to be more prominent than the physical side effects, or at least more easily measured.

 

[aim-agm]

Diphenhydramine (so many older folks taking Tylenol PM), oxybutynin, quetiapine, the triptylines, hydroxyzine, paroxetine, and many others. The big issue is that they are additive in nature, so even if you take a handful of milder ones, we still generally see negative cognitive side effects, which tend to be more prominent than the physical side effects, or at least more easily measured.

I don't blame folks for missing that Tylenol PM has diphenhydramine (Benadryl) in it, but boy does it come up a lot.
One frustration I have is that people claim quetiapine is not anticholinergic, which while technically kind of true (Ki on the order of 100-1000 nM) it's active metabolite norquetiapine is very anticholinergic (Ki ~20 nM).
I'll correct you about hydroxyzine - it is very low affinity for muscarinic receptors (Ki 4600 nM), especially compared to its H1 affinity (2 nM), although a caveat is that it seems H1 inverse agonism itself leads to a degree of anticholinergic effect so in a sense all antihistamines are anticholinergic.

 

[WisNeuro]

I don't blame folks for missing that Tylenol PM has diphenhydramine (Benadryl) in it, but boy does it come up a lot.
One frustration I have is that people claim quetiapine is not anticholinergic, which while technically kind of true (Ki on the order of 100-1000 nM) it's active metabolite norquetiapine is very anticholinergic (Ki ~20 nM).
I'll correct you about hydroxyzine - it is very low affinity for muscarinic receptors (Ki 4600 nM), especially compared to its H1 affinity (2 nM), although a caveat is that it seems H1 inverse agonism itself leads to a degree of anticholinergic effect so in a sense all antihistamines are anticholinergic.

I was wondering if someone was going to bring that up 🙂 Definitely, but it does still seem to contribute to the ACB and is included on most of the scales. I haven't seen anything looking at hydroxyzine and cognitive decline in isolation, but I'd imagine that sample would be difficult to come by.

 

[Therapist4Chnge]

I just ran into this w an older patient a couple weeks ago. They hadn’t told their prescriber they were taking Tylenol PM on top of their regular meds, and they saw a spike in anticholinergic side effects and some cognitive blunting. Not rocket surgery, but a good reminder for them bc they prev told their prescriber they took Tylenol during their intake and didn’t specify.

 

[WisNeuro]

I just ran into this w an older patient a couple weeks ago. They hadn’t told their prescriber they were taking Tylenol PM on top of their regular meds, and they saw a spike in anticholinergic side effects and some cognitive blunting. Not rocket surgery, but a good reminder for them bc they prev told their prescriber they took Tylenol during their intake and didn’t specify.

I recently saw a patient who was not having sleep problems to begin with, but started taking Tylenol PM as a prophylactic, just in case they started to have sleep problems! And another one, where after taking one Tylenol PM for a while, was still having sleep problems, so started taking 2-3 every night.

 

[quickpsych]

Try taking away “grandma’s little helper” (benzo) and you’ll get knitting needles to the eye or worse.