Recent data show that widespread discrepancy exists between clinical guidelines and practice patterns for ADHD, dementia, and bipolar disorders.
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1. Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, et al. American Academy of Pediatrics. Clinical Practice Guideline. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2011;128:1007-1022.
2. American Academy of Child and Adolescent Psychiatry. Atypical Antipsychotic Medication. http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf.
3. Olfson M, King M, Schoenbaum M. Treatment of young people with antipsychotic medications in the United States. JAMA Psychiatry. 2015;72:867-874.
4. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631.
5. Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings. GAO-15-211: Published: Jan 30, 2015. See: http://www.gao.gov/assets/670/668221.pdf.
6. Pacchiarotti I, Bond DJ, Baldessarini RJ, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. Am J Psychiatry. 2013;170:1249-1262.
7. Viktorin A, Lichtenstein P, Thase ME, et al. The risk of switch to mania in patients with bipolar disorder during treatment with an antidepressant alone and in combination with a mood stabilizer. Am J Psychiatry. 2014;171:1067-1073.
8. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458-1465.
A widespread discrepancy exists between clinical guidelines and practice patterns for ADHD, dementia, and bipolar disorders.
Many professional associations compose and disseminate practice guidelines that recommend specific treatment approaches with the hope that standardized protocols will improve quality of care. Clinicians, however, have not universally adopted these guidelines.
Clinical guidelines improve health care by moving away from unexamined reliance on professional judgment toward more structured support and accountability for such judgment. Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. See: Clinical Practice Guidelines: Directions for a New Program
Neither the American Academy of Pediatrics nor the American Academy of Child and Adolescent Psychiatry recommend the use of antipsychotics for ADHD. Despite this, Olfson and colleagues found that antipsychotics were the most commonly used prescriptions for children and adolescents diagnosed with ADHD.
In addition to FDA warnings, the American Geriatrics Society Updated Beers Criteria state that use of antipsychotics for behavioral problems of dementia should be avoided unless nonpharmacological options have failed and patient is a threat to self or others. However, according to a 2015 US Government Accountability Office report, approximately 33% of older adult Medicare Part D enrollees with dementia who reside in a Nursing Home are prescribed antipsychotic drugs.
The International Society for Bipolar Disorders (ISBD) Task Force states that antidepressant monotherapy should be avoided in bipolar I disorder. While concerns regarding antidepressant poor effectiveness and potential for manic switch are acknowledged, Viktorin and colleagues found that bipolar disorder is treated with antidepressant monotherapy in nearly 35% of patients.
The impediments to physician adherence to guidelines that Cabana and colleagues identified in 1999-such as awareness, familiarity, agreement, self-efficacy, outcome expectancy, ability to overcome the inertia of previous practice, and absence of external barriers to perform recommendations-have not yet been overcome.