Choosing Wisely –
shared decision making
We are supporting an initiative called Choosing
Wisely, which aims to improve conversations between
patients, carers and clinicians, and help choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already
- Free from harm
- Truly necessary
We worked with members of the college to create a list of tests,
interventions or treatments, which are not supported by best
available evidence. We, as the representative body of UK
psychiatrists, think they are therefore unnecessary or potentially
harmful. We hope this list will generate discussion and debate. In
the coming months we will continue to work with each of the
of the Royal College to develop lists for each specialty.
Adult mental health
In the treatment of depression, if an
antidepressant has been prescribed within the
therapeutic range for 2 months with little or no response, it
should be changed or another medication added.
When adults with schizophrenia are introduced
to treatment with long-term anti-psychotic medication, the benefits
and risks/disadvantages of taking oral medication compared to
long-acting depot injections should be discussed
with all relevant parties.
Women who are able to conceive should not be
prescribed valproate for mental disorders except
where there is treatment resistance and/or very high risk clinical
situations. All other options should have been considered and/or
tested and all the risks and contraceptive options should be
discussed with all relevant parties.
When a diagnosis of psychosis is made,
CT or MRI head scans should only be used for
specific indications i.e. signs or symptoms suggestive of
Cognitive testing alone does not diagnose
dementia - in order to establish an accurate
diagnosis of dementia it is recommended to obtain a
full history, collateral information from key
family members and a cognitive assessment.
Aim to use non-drug treatments for the
management of behavioural and psychological symptoms of
dementia. If there are significant risks that make
treatment with an antipsychotic necessary, this
should be discussed with the patient and their family, and the
lowest possible dose used.
Do not forget pain as a common cause of
agitation in patients with
dementia. Consider prescribing regular
analgesia such as paracetamol if there is
clinical suspicion that pain is a relevant trigger.
Antipsychotics can cause serious side effects
in patients with Lewy Body Dementia. They should
only be used under expert guidance.
Anticholinergic drugs can be detrimental to
cognition in later life and have other serious
side effects. Careful consideration of the risks to patients,
including the use of an anticholinergic burden scale, should be
undertaken prior to initiation.
Older adult mental health
Do not refuse patients access to a service,
investigation or treatment solely on the basis of their age.
Decisions should be based on need.
Management of older adults with mental problems should be guided
by Old Age specialists, who are able to manage the
complex needs of this population.
The care of frail older adults with complex
needs who need an inpatient admission, is best managed in
an older person's specialist ward environment.
Do not use physical restraints in older adults
in hospital settings with delirium except as a
If benzodiazepines or
antipsychotics drugs have been initiated during an
acute care hospital admission, make sure there is a clear plan to
review their use, ideally tapering and
discontinuing prior to discharge.
Daniel Maughan, our Associate Registrar for
Sustainability, has written a blog
introducing this initiative to the college. A BMJ Editorial
was also published to launch the Choosing Wisely
initiative. Choosing Wisely started as a
doctor-led initiative in the USA and then
Canada and is being
led in the UK by the
Academy of Medical Royal Colleges.
If you would like to get in touch with the College about the
Choosing Wisely campaign, please contact Thomas