ARE we too quick to prescribe psychotropic medication for emotional and behavioural problems? Take Alzheimer鈥檚 disease. In an attempt to reduce their aggressive behaviour, up to 60 per cent of people with Alzheimer鈥檚 in Europe and North America are prescribed antipsychotic medications such as Risperdal (risperidone) and Zyprexa (olanzapine). The estimated cost of these drugs is 拢80 million a year in the UK alone.
People given antipsychotics are sedated and become less aggressive or agitated, but compared with placebo the benefits seem modest at best. In 2006, a 42-centre trial in the US found no significant differences between antipsychotic drugs and placebo after 12 weeks. Other trials showed some advantages of drugs over placebo, but these were 鈥渕odest鈥� ().
The risks, however, are large. According to the UK Medicines and Healthcare Products Regulatory Agency, the medication produces a (). The drugs also double the risk of dying over a three-year period, according to a study funded by the UK鈥檚 Alzheimer鈥檚 Research Trust ().
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Last week, 10 dementia groups, including the trust, demanded the UK government publish a long-delayed review of the use of antipsychotic drugs in dementia.
The issue is not that people don鈥檛 improve when given antipsychotic drugs: they do. But so do patients in trials who are given a placebo, and they improve nearly as much as those given the drug.
This may be good news for Alzheimer鈥檚 patients, as a strong placebo effect means non-drug treatments may work well. There may be lessons to be learned here from similar treatments for depression 鈥� which also responds well to placebo, and only minimally better to drugs.
Traditional psychotherapy, which works for depression, might be little use to cognitively impaired people. But cognitive behavioural interventions have shown benefits: for example, in one small UK study of five patients, such techniques were found to help control aggressive and agitated behaviour (International Journal of Geriatric Psychiatry, vol 16, p 45). Exercise 鈥� which is even more effective for moderate to severe depression than for mild to moderate depression 鈥� has also shown promise for diminishing aggression. A structured walking programme in one nursing home resulted in a 30 per cent decrease in aggression among severely demented patients (Archives of Psychiatric Nursing, vol 11, p 21).
A 鈥渃onsensus statement鈥� by 16 practitioners published last year in The Journal of Clinical Psychiatry (vol 69, p 889) urged that antipsychotic drugs be used to treat dementia-related agitation and aggression 鈥溾��. Research on non-drug treatments is thin on the ground, but with millions facing dementia, we urgently need them in our armoury.
