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Evidence-Based Use of Antipsychotics: A Quick “How To”

Evidence-Based Use of Antipsychotics: A Quick “How To”

  • What Is Evidence-Based Medicine?
  • Number Needed to Treat
  • What Is Treatment Effectiveness?
  • What’s Different Among the  “Metabolically-Friendly” SGAs?
  • Final slide

How can you apply the framework and philosophy of evidence-based medicine to the use of antipsychotic medication?

Here to discuss is Leslie Citrome, MD, MPH. Dr Citrome is Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla. He is a scheduled speaker at this year's US Psychiatric and Mental Health Congress in Las Vegas.

Here is a brief summary of some of the points Dr Citrome makes in his 5-minute audio presentation:

•Evidence-based medicine is not cookbook medicine. It means pairing your clinical judgment with the relevant scientific evidence and including your patients’ values and preferences into making a decision for your patient. It’s about individualizing therapy.

•Treatment effectiveness is not just efficacy; it is also the combination of efficacy plus tolerability plus adherence.

•When appraising evidence of a drug’s efficacy, number need to treat (NNT) and number needed to harm (NNH) are favorite tools. We can use these tools to indirectly compare the new antipsychotics with one another, for example. With ilopederidone, asenapine, and lurasidone, we can calculate where the data are available: how many patients does it require to be treated with any of these agents versus placebo before we can expect to encounter one additional responder? Those agents with a lower NNT would be expected to be more efficacious. We need to balance this as well with safety and tolerability outcomes. The product labels for each of these new agents list commonly encountered adverse effects. We can calculate NNH to cause (for example) sedation or akathesia or weight gain of at least 7% from baseline. By doing so, we can figure out where these drugs indirectly compare with each other. For NNH, the higher the number the better. The NNH should be double digit so that we don’t encounter that harm very often.

•Other factors to consider when looking at the new agents include how often per day these agents are taken; does the drug need to be taken with or without a meal or liquids; what are the warnings regarding prolactin, QT prolongation, and perhaps pregnancy category . . . all these factors may be influential depending on the patient you are treating.

Further reading:

Citrome LL. A review of the pharmacology, efficacy and tolerability of recently approved and upcoming oral antipsychotics: an evidence-based medicine approach. CNS Drugs. September 2013. http://link.springer.com/article/10.1007/s40263-013-0105-7.

Citrome LL. New second-generation long-acting injectable antipsychotics for the treatment of schizophrenia. Expert Rev Neurother. 2013;13:767-83.


In some situation I believe the clinical judgment more than anything else others I believe in scientific data and so on. I mean are the 3 circles equal in all situations or there is a 4 th dimension make them of different equality?

Adel @

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Just a suggestion,
Stephanie Maine

Stephanie @

Dr Citrome is a heavy duty speaker for pharmaceutical and his comments should be taken with a grain of salt. He can not be free from bias in his aseverations. He should not play both bands.

Manuel @

Dr. Citrone, I appreciated your presentation's approach to blended decision inputs in treatment choices. It would have been really helpful if your chart had included the NNT and NNH for each medication explicitly. (If this is referenced elsewhere and you can provide a citation I'd appreciate it.) It would also have been helpful if the chart had included the evaluative time frames for assessing each medication's performance (if differences exist) as one might consider how long one might have to attempt a medication (with its attendant risks) before being able to determine whether it was having a positive affect for that patient, and so that a decision to switch or discontinue could be made in a timely way to avoid unneeded exposure to an unhelpful medication's effects.

I do not share David's view below regarding evidence based medicine being a gimmick. I feel that it can be very helpful in evaluating and individualizing medical strategies for individual patients. As for insurance companies...well, they aren't known for their support of psychiatric treatment in any case and they hardly need evidenced based medicine as an excuse to deny a claim, they have plenty of expertise in that area already.

For those that have practiced for extended periods, I am certain that the intention to practice good and helpful medicine was present for all. Still, there is no profession that can't grow and improve its ability to be of help to those they serve. Similarly, rational practice can be refined with increased access to information and other decision tools. All professions have to challenge their own preconceived notions on a regular basis to weed out those that may have been superseded by new information or root out practices based more in habit than in fact, psychiatry is not alone in that, nor is it alone in the need to place professional pride aside to accomplish these self reviews (which are never comfortable!).

Stephanie Maine

Stephanie @

Les Citrome does a remarkable job making complex concepts accessible to recipients, advocates, providers, and other psychopharmacologists

Lewis @

LS! Robert Trivers writes in "The folly of fools" that 60% of the genes of a human is active in the brain, and nobody understands what these genes do. Since genes are highly individual, people differ much more from each other then generally is assumed by science and research. Therefore science, be it psychology or psychiatry, should not assume so much likeness between people. I hope I quote the world's best biogeneticist Robert Trivers correctly.

Sebastiaan @

good discuss

radhouane @

"Evidence-medicine" is a gimmick used by insurance companies to deny needed care. This is all, in plain language, a crock. I have been practicing psychiatry for 30 years. It is insulting for anyone - especially another psychiatrist - to imply that we were not practicing in a rational manner (albeit without the catch-word) 30 years ago - as well as during my residency and during medical school, even further back. This is nothing new. It's being a toady for corporations to manipulate medical care and for researchers who get all excited when they re-discover the wheel and give it a name. What a waste of good font...


To David, Hear! Hear! As a colleague said, "Evidence-Based Practice? Fine, I'll consider it. But what about Practice-Based Evidence?".


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