The routine use of antipsychotics, like Zyprexa (olanzapine) and Seroquel (quetiapine), should not be used to treat primary insomnia in children, adults or the elderly, say Canadian psychiatrists. This information is part of a series of 13 evidence-based recommendations made by the Canadian Psychiatric Association (CPA) and its working group partners, the Canadian Academy of Child and Adolescent Psychiatry (CACAP) and the Canadian Academy of Geriatric Psychiatry (CAGP), for the Choosing Wisely Canada campaign.

Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care.

So begins the press release announcing the 13 recommendations made jointly by these three bodies as part of Choosing Wisely Canada.

The full list is this week’s Reading, and “Thirteen Things Physicians and Patients Should Question” can be found here:

Choosing Wisely is a good campaign – thoughtfully done and executed. It ultimately aims to better patient care. It’s also important within the context of the larger system itself.

Let me pick up on the last point by drawing attention to the work of an important health-care analyst. Will Falk leads the Healthcare Services group at PwC. He’s been very influential in Ontario and beyond – his influence can be felt in everything from the Drummond report to the current OMA negotiations. In the just-released “Is Deflation of Healthcare Costs a Good Thing?” he emphasizes the heavy rise in health-care costs in the later years of the last decade, with spending as a percentage of GDP soaring up and pushing at 12% in 2008.

Source: CIHI

Not surprisingly, he notes that governments “applied the breaks.” Ontario health spending as a percentage of GDP is down 1.4% since 2009, as an example. Falk argues that that this current deflationary period could be different than past periods in that several system changes are occurring. He notes that governments are focusing more on “frequent fliers,” heavy users of health care, hoping to do better disease management. Following his argument, we may be entering into a time of smarter spending. We’ll see. (And, historically, health-care deflation is connected to labour unrest and public angst.)

Will Falk

But in an age of restraint, Choosing Wisely Canada has added significance, encouraging doctors and patients to think about what is necessary and what isn’t.

In his recent New Yorker essay, Dr. Atul Gawande notes the treatment of back pain. As you will recall (this essay was featured in the 21 May 2015 Reading), Dr. Gawande notes that when back pain is not accompanied by neurological symptoms, there is limited evidence for surgery or even imaging. Yet “one study found that between 1997 and 2005 national health-care expenditures for back-pain patients increased by nearly two-thirds, yet population surveys revealed no improvement in the level of back pain reported by patients.”

Started in the United States by the ABIM Foundation, Choosing Wisely aims to empower both physicians and patients with better information. Dr. Wendy Levinson oversees the Canadian project.

Dr. Wendy Levinson

So, is there a psychiatric equivalent of the overtreatment of back pain? In terms of unnecessary surgeries, there isn’t, of course. But the list attempts to address the fact that some common problems are mishandled. Among them: doctors prescribe SSRIs for depressed teens when evidence suggests that CBT or IPT is superior (recommendation 2); benzodiazepines are used in the elderly for primary insomnia but are linked to hip fractures and MVAs (recommendation 13); combinations of antipsychotics for people with schizophrenia are used but offer no advantage over monotherapy (recommendation 11).

Which brings us back to insomnia (recommendation 5):

Do not routinely use antipsychotics to treat primary insomnia in any age group.

The list notes potential side effects, like weight gain. What to consider besides antipsychotics? The press release answers:

Instead, the CWC psychiatry working group recommends that a thorough assessment to establish possible behavioural (e.g., poor sleep-wake schedule, use of caffeine and nicotine), emotional (e.g., stress), psychiatric, or physical (e.g., pain, sleep apnea) causes for insomnia be conducted. Nonpharmacological interventions, such as sleep hygiene techniques and behavioural modification, should be the first treatment option offered in most cases. Melatonin, an over-the-counter hormone supplement, may also be used to help regulate sleep-wake cycles.

This is a solid list of recommendations – worth reading and worth thinking about. For the record, I really like recommendation 9.

Further Reading…

For more on Choosing Wisely Canada, see:

For Falk’s “Is Deflation of Healthcare Costs a Good Thing?” see:

And on a lighter note, set to “Happy,” he’s a music video on Choosing Wisely:

(Thanks to Dr. Paul Benassi for that link.)

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.