Choosing Wisely: Wise Choices in Psychiatry

Since 1999, the National Institute for Health and Clinical Excellence (NICE) has identified more than 800 practices that are not effective or good value.9 A recent Australian study reviewed 5209 articles, resulting in 156 health care practices identified and flagged as potentially unsafe, ineffective, or inappropriate in certain circumstances.10 Another study reviewed a decade of literature in high-impact journals to reveal 146 contradicted medical practices; it found reversals for medications, procedures, diagnostic tests, screening tests, and even monitoring and treatment guiding devices. The time and expense required for physician follow-up visits and medication acquisition are often diverted from resources otherwise directed to family, education, employment, or other personal interests.19 The causative effects of social factors such as working conditions, education, financial status, and social values may be undervalued by perfunctory psychotropic prescribing and simplistic ''blaming the brain'' for distressing mental states.34 Adverse effects to antidepressants in research studies led to 10% to 20% of patients discontinuing the medication.35,36 While most adverse effects are manageable or temporary, some can be serious.37 Inadvertent drug interactions, such as citalopram with azithromycin causing prolonged QT/QTc intervals, can have fatal consequences.38,39 The consequences of changes to neurotransmitter receptor regulation or dendritic proliferation, both associated with antidepressant use, in the context of prescribing without an approved indication are not fully understood and should promote a sense of caution.40-42 Antidepressant prescribing may lead to a labelling effect or perception of a confirmed genetic risk for depression.