The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.
Letters to the Editor
As a psychiatrist in private practice, I share some of the concerns about quetiapine raised by Jonathan Brett (Aust Prescr 2015;38:95-7). However, I think there is a significant role for off-label prescribing in certain patient groups. Patients with major depression, particularly those with agitation, high degrees of inner distress, or sleep difficulties often benefit substantially when quetiapine, usually 12.5–100 mg, is added to their antidepressant. The 25 mg tablet is most appropriate for this use.
If it is claimed that ‘quetiapine has proven safety and efficacy when used for its approved indications’, which usually entail 400–800 mg doses, I do not think further studies are needed to conclude a 25 mg dose will be safer than a 400–800 mg dose. As it is, undertreating a depressed patient’s distress also carries significant risks. These risks are difficult to analyse as depressed patients who become suicidal usually get booted out of depression studies. As a result, there is a significant validity issue regarding the ‘evidence’ because patients who participate in depression studies differ from many of those who come through a psychiatrist’s door. Indeed, those most at risk of suicide are the ones we tend to have the least evidence about to guide our management. The ‘no evidence, so don’t use it’ mantra may well work against the welfare of many depressed patients. Evidence is a tool, not a god, and the flaws in the evidence need to be fully understood before ‘evidence’ is used to formulate management guidelines.
Another area concerns personality disorders, which are difficult to treat. Psychological treatment should be the mainstay, but many patients are not very psychologically minded, and psychological treatment doesn’t always work, even among those who want to change. Yet patients with personality disorders often have high levels of distress. The ‘no evidence, so don’t use it’ mantra may again work against patient welfare, compared to the judicious use of low-dose quetiapine for such patients when they are in crisis.
Thus, quetiapine has its problems, but off-label use remains an important tool in certain clinical situations.
Dee Why, NSW
I would like to comment, as a GP, on Jonathan Brett’s very timely article. I have a sizeable geriatric population in my practice, of which a fair number with evolving or full-blown dementia are in institutions. This is the area in which quetiapine use is relevant. Quetiapine 6.25–100 mg per day is very effective to calm patients down and help them to coexist with other institution residents or family members at home.
It goes without saying that anxiety, insomnia and depression are all looked for and treated first. Quetiapine (and other antipsychotics) are not used willy nilly. There is not much else to use and the ubiquitous benzodiazepines have a bad reputation. Risperidone at its recommended dose (by the Pharmaceutical Benefits Scheme – PBS) is often not effective enough for the agitated, noisy patient who needs to be controlled quickly. If the patient is over-sedated, family members complain and staff report hazardous falls. We respond accordingly.
Drugs used off label are written as private scripts, so PBS attempts to curtail quetiapine’s use will not be effective. Non-pharmacological interventions always sound good, but for Australia’s evolving institutions that have to grapple with the growing dementia population, these interventions are often disappointing in effect because qualified personnel to execute them are not easily available.
What we need are studies into quetiapine’s role in these types of patients, not roadblocks against its use. If the researchers did it for risperidone, why not for quetiapine?
Port Adelaide, SA
I was interested to read the June article by Jonathan Brett on the increase in prescribing of quetiapine, particularly at lower doses.
I am a GP who has contributed to those statistics due to the new phenomenon of telehealth. I work in a rural country town and have an interest in mental health and psychological medicine. I have participated in telehealth sessions with consultant psychiatrists by sitting in and providing support and follow-up. This has involved quite a lot of work with adolescents and young adults. As the GP at the consultation end of the interaction, I am providing the prescriptions recommended in the psychiatrist’s management plan.
The phenomenon of telehealth therefore may interfere with the statistics and information about who is prescribing quetiapine. I wonder how many other GPs are prescribing quetiapine in this way. The prescriber number statistics may not be truly reflecting the basis of these decisions.
I read with interest the article about the increasing off-label use of quetiapine. Indeed it is often used for insomnia, for example, and this is my focus. In general practice I do not see it used with personality disorders, dementia, or substance abuse, and only rarely in post-traumatic stress disorder and anxiety. That is not to say that it may not be useful in these disorders in specialised hands, but may not be indicated as prime therapy. It is nonetheless unfortunate when a medicine is denied to an individual when it suits them well, simply on the basis of esoteric and inclusion criteria-limited epidemiological studies. The dicta of evidence-based medicine do not always serve us well in this regard.
In his article, Jonathan Brett commented that there was poor evidence for quetiapine in insomnia. He quotes one recent literature review that found only two placebo-controlled trials and concluded that the absence of safety and efficacy data precludes the use of quetiapine for insomnia.1 Another review he quoted was from a nursing journal.2 It in fact identified five studies, and three randomised controlled trials. All but one of them suggested sleep benefit from quetiapine. Two further studies reported the weight gain associated with quetiapine. The review goes on to say clinicians should consider individual patient health profiles in light of the potential weight gain with long-term quetiapine therapy.
The ascription ‘off-label’ seems to indicate a pejorative connotation. I would dispute this. Clinical judgement should always govern prescribing. Medication is always prescribed on balance. If the concern is sleep versus weight gain, and this seems the only concern mentioned, the lack of sleep and its deleterious effects may well transcend the appearance of weight gain. Nonetheless there seems to be more evidence in favour of usage in insomnia than was quoted.
Chapel Hill, QLD
- Anderson SL, Vande Griend JP. Quetiapine for insomnia: A review of theliterature. Am J Health Syst Pharm 2014;71:394-402.
- Carney AC. Efficacy of quetiapine off-label uses: data synthesis. JPsychosoc Nurs Ment Health Serv 2013;51:11-8.
- Walton SM, Schumock GT, Lee KV, Alexander GC, Meltzer D, Stafford RS. Prioritizing future research on off-label prescribing: results of a quantitative evaluation. Pharmacotherapy 2008;28:1443-52.
- Thompson Coon J, Abbott R, Rogers M, Whear R, Pearson S, Lang I, et al. Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: a systematic review. J Am Med Dir Assoc 2014;15:706-18.
- Gerhard T, Lucas J, Crystal S. Abstract 160: Association between nursing home staffing levels and off-label use of antipsychotics. Pharmacoepidemiol Drug Saf 2008;17 Suppl 1:S1-294.
- Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458-65.
- Anderson SL, Vande Griend JP. Quetiapine for insomnia: A review of the literature. Am J Health Syst Pharm 2014;71:394-402.
- Cates ME, Jackson CW, Feldman JM, Stimmel AE, Woolley TW. Metabolic consequences of using low-dose quetiapine for insomnia in psychiatric patients. Community Ment Health J 2009;45:251-4.
- Gazarian M, Kelly M, McPhee JR, Graudins LV, Ward RL, Campbell TJ. Off-label use of medicines: consensus recommendations for evaluating appropriateness. Med J Aust 2006;185:544-8.
- Council of Australian Therapeutic Advisory Groups. Rethinking medicines decision-making in Australian hospitals: guiding principles for the quality use of off-label medicines. Sydney: CATAG; 2013.
- Walsh T, Barr PJ, Thompson R, Ozanne E, O’Neill C, Elwyn G. Undetermined impact of patient decision support interventions on healthcare costs and savings: systematic review. BMJ 2014;348:g188.
- Choosing Wisely Australia, an initiative of NPS MedicineWise. Sydney: NPS MedicineWise; 2015. www.choosingwisely.org.au [cited 2015 Nov 4]