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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Office of Mental Health Letterhead

OMH Advisory On Antipsychotic Medication Use In Adults

Lloyd I. Sederer, MD
Medical Director

February 16, 2009

Dear Colleague,

This OMH Advisory is on the use of antipsychotic medications (APs) for adult patients served by the New York State Office of Mental Health. We hope these comments will be of value to others in the mental health community.

There is mounting evidence, now reported in a variety of journals and the popular press, that:

  • although there are differences between individual AP drugs there are neither clear nor consistent distinctions in the clinical effectiveness between first and second generation APs (with the exception of clozapine) as classes of drugs
  • there are significant risks of prescribing APs to individuals with dementia - See OMH Advisory.
  • there are cardiometabolic risks associated with specific first and second generation APs
  • there are risks for neurologic extrapyramidal side effects with specific APs, particularly the higher potency first generation APs
  • there is a small risk of sudden cardiac death associated with APs

All medications carry risks (and have side effects). The work of prescribing clinicians is to identify benefit and risk and help patients make informed decisions about their health and treatment.

Antipsychotic medications remain a mainstay in the effective treatment of psychotic illnesses thereby calling for even greater care regarding which agent we recommend to each individual patient - and what monitoring we provide before and during the course of treatment. Recall, as well, that the risk of relapse is far greater in people with psychotic illness if they do not take APs - as noted in OMH Advisory on APs.

Recent concerns about the risk of sudden cardiac death in people taking APs led the American Psychiatric Association (APA) to issue the attached guidance document. This release comes from the APA Council on Research, chaired by Dr. Jeffrey Lieberman, the Director of the New York State Psychiatric Institute and Chair of Psychiatry at Columbia.

The OMH Medical Director's office is working with Dr. Lieberman on a template to provide guidance to each OMH prescribing clinician to review the AP medications of all their patients. We envision a decision tree for existing patients at the time of their next appointment and for all new patients. This is a complex endeavor and one that warrants the careful thought of experts, which we have undertaken. We hope that this work also will be useful to colleagues outside of the OMH.

As you see your patients, please be sure to continue to consider benefit, risk, side effects, drug-drug interactions, the lowest doses possible for effectiveness, and the importance of psychosocial treatments for all patients who meet indications for the prescription of an AP medication (or any medication for that matter).

We welcome your comments.
Please feel free to distribute this material to your colleagues.

Sincerely,
Lloyd I. Sederer, MD
Medical Director, NYS Office of Mental Health

Attachement: APA Guidance on the Use of Antipsychotic Drugs and Cardiac Sudden Death