Assessment and management of behavioral and psychological symptoms of dementiaBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h369 (Published 02 March 2015) Cite this as: BMJ 2015;350:h369
All rapid responses
In a comprehensive and interesting State of the Art Review (1), the authors report that antipsychotics kill 1 for every 100 patients treated (3.5% died on drug and 2.3% on placebo) based on a meta-analysis of trials that ran only for 10-12 weeks (2). Thus, the death risk is likely even greater in clinical practice, also because polypharmacy is very common in the elderly. The authors conclude that:
“Of all agents currently used for behavioral and psychological symptoms of dementia, atypical antipsychotics have the strongest evidence base, although their benefits are moderate at best (effect size 0.13-0.16). Any such benefits must be balanced against the risk of adverse events, including mortality.”
Placebo controlled trials of psychiatric drugs are poorly blinded, however. Due to the conspicuous side effects of these drugs, most patients and doctors break the blind (3). This means that such small effect sizes can be fully explained by unblinding bias (4). We should not use deadly drugs with doubtful benefits. Antidepressants also kill many elderly people. A cohort study of patients older than 65 who were their own control found that all cause mortality was 3.6% higher when patients were taking the newer antidepressants for one year than when they did not take antidepressants (5).
Therefore, we should not use any psychiatric drugs for dementia (3), not even anti-dementia drugs, as they don’t work either (1,3) and have rather terrible side effects, e.g. the most common side effects of donepezil are: nausea, diarrhea, not sleeping well, vomiting, muscle cramps, feeling tired, and not wanting to eat. Many demented people already have such problems, and we would not like to worsen them, would we?
1 Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ 2015;350:h369.
2 Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934–43.
3 Gøtzsche PC. Deadly psychiatry and organised denial. Copenhagen: People’s Press 2015 (in press).
4 Hróbjartsson A1, Thomsen AS, Emanuelsson F, et al. Observer bias in randomized clinical trials with measurement scale outcomes: a systematic review of trials with both blinded and nonblinded assessors. CMAJ 2013;185:E201-11.
5 Coupland C, Dhiman P, Morriss R, et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011;343:d4551.
Competing interests: No competing interests