Choosing Wisely – deciding on care together

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 duplicating other tests or procedures the patient has already received
• 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 the 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.

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 neurological problems.

Dementia care

• 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 last resort.
• If benzodiazepines or antipsychotic 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.

A BMJ Editorial was 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.