We thank the editors of the BCMJ for the opportunity to respond to Dr Passmore’s thoughtful letter [10]. He provides several important points as well as a context for these difficult and challenging situations. 

We tried to make three points in our original letter: that a large percentage of second-generation antipsychotic (SGA) use in British Columbia is for the management of the behavioral and psychological symptoms of dementia (BPSD); that this use is off-label (apart from short-term use of risperidone); and that the literature suggests an increased signal of harm with respect to mortality and in­creas­ed cerebrovascular accidents.[1] 

We took the opportunity to review the UK government–sponsored review in which numbers needed to treat (NNT) are quoted as ranging from 5 to 11.[2] They conclude “antipsychotic drugs show minimal efficacy for the treatment of BPSD” and summarize the risks and benefits using NNT and numbers needed to harm as follows: that treating 1000 people with BPSD with an atypical antipsychotic drug for around 12 weeks would result in an additional 91 to 200 patients with behavior disturbance showing clinically significant improvement in these symptoms; an additional 10 deaths; an additional 18 cerebrovascular accidents, around half of which may be severe; and an additional 58 to 94 patients with gait disturbance.[2] Such information is useful for clinicians to make informed decisions.

We fully agree with Dr Passmore that that there is a cohort of patients who fail a trial of all other environmental and pharmacological strategies and in whom these agents have to be used as a last resort to improve the quality of life. Our plea to our colleagues is that these agents not be used as a first-line agent, but rather a last resort for the shortest period of time with frequent attempts at cessation.
—Mark Fok, MD
—Larry Dian, MD
Vancouver

References

1.    Ballard CG, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev 2006 Jan 25;(1):CD003476. DOI: 10.1002/14651858.CD003476.pub2.
2.     Banerjee S. UK The use of antipsychotic medication for people with dementia: Time for action. Department of Health. Accessed 4 June 2012. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalas... [11].