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What do we do when the antipsychotics are gone?

The agents referred to as “unnecessary drugs” or “chemical restraints” in skilled nursing facilities go by another name in hospitals and outpatient settings. They're called “medicine.”

For some time, nursing homes have been under tremendous pressure to reduce or eliminate the use of antipsychotics, and now benzodiazapines are starting to receive similar attention. Obviously there are many benefits to reducing the use of medications that are not effective, especially those that cause deleterious side effects. But the vast majority of residents in these facilities have significant psychiatric disorders, and staff members are confronted by challenging behaviors on a daily basis.

Let's face it, nursing homes are mental health settings just as much as they are medical environments. Most residents in nursing homes suffer from dementia with behavioral disturbances, a mood disorder, or both. Factoring in other residents who are admitted with pre-existing histories of chronic psychiatric illness, there is a clear, widespread need for evidence-based treatment of psychiatric illness and behavioral disorders in post-acute care. One could argue that effectively treating and managing behavioral issues — the “psychosocial” elements of the biopsychosocial model — is the most important factor in providing excellent post-acute care.

Because facilities are being asked to reduce the use of antipsychotics and other “unnecessary drugs” while simultaneously providing excellent care, there must be a fundamental shift in their approach to care delivery. Simply reducing the use of psychotropic drugs would have deleterious outcomes, including psychiatric hospitalizations, resident-to-resident attacks, abusiveness towards staff, staff attrition, unhappy families, poor survey results and declining 5-Star ratings.

The study demonstrates that changes in the care environment — exactly those improvements in resident care that should come from the psychological assessment of residents and implementation of an individualized, “person-centered” approach to care — were shown to be more effective than antipsychotics in managing behavioral symptoms. But the gains involved go well beyond the residents, as these types of approaches lead to improvement in staff and family satisfaction as well.Creating this type of psychologically informed, individualized approach to care begins with an appreciation of many resident variables, including:

  • Underlying personality structure, psychiatric history and baseline mood
  • Historical response to personal challenges
  • Interpersonal style and reactivity
  • Individualized response to situations and events that trigger problematic behaviors
  • Strengths and weaknesses in a variety of cognitive, emotional and interpersonal domains
  • Optimal levels of resident involvement in care planning and other decision-making

For more from Richard Juman Psy.D. in McKnight's, click here.