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• W2011196810 abstract "Back to table of contents Previous article Next article Communications and UpdatesFull AccessResponse to Nasrallah LetterHelen C. Kales, M.D., Frederic C. Blow, Ph.D., and Lon S. Schneider, M.D., M.S.Helen C. KalesAnn Arbor, MichiganSearch for more papers by this author, M.D., Frederic C. BlowAnn Arbor, MichiganSearch for more papers by this author, Ph.D., and Lon S. SchneiderLos AngelesSearch for more papers by this author, M.D., M.S.Published Online:1 Jun 2012https://doi.org/10.1176/appi.ajp.2012.12020279rAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: As Dr. Nasrallah notes, our data provide confirmation of the higher mortality associated with haloperidol when compared with atypical antipsychotics in patients with dementia (1). The main finding and unique contribution of our paper, however, is that there are mortality risk differences between atypical antipsychotics, with risperidone and olanzapine having higher mortality rates than quetiapine. Since the publication of our article, our findings of differential mortality among individual antipsychotics have been confirmed in another sample (2).Dr. Nasrallah also brings his pilot study (3) to our attention. This retrospective study at a single center reported higher rates of 2-year mortality for patients taking haloperidol in comparison with those taking atypical antipsychotics. However, as noted in a letter to the editor regarding that paper (4), the study did not control for the known selection biases that occur in patients treated with haloperidol compared with atypical antipsychotics. Haloperidol tends to be prescribed for patients older and sicker than those treated with atypical antipsychotics (5). In our study, we analyzed a wide array of potential confounding factors in addition to using propensity methods to control for potential treatment-by-indication bias. In doing so, we observed the mortality action of haloperidol occurring within the first 30 days of treatment. Therefore, it is unclear that one could conclude that neurotoxicity is the mechanism of mortality risk.In light of our data, the evidence from randomized controlled trials, and a number of retrospective database studies, we find no support for the idea that atypical antipsychotics are neuroprotective in patients with dementia. Randomized trials have shown atypical antipsychotics to have 1%–2% higher risk than placebo over 10- to 12-week study periods (6). Over the longer 6-month follow-up in our cohort, olanzapine and risperidone showed mortality rates of approximately 27 deaths per 100 person-years of treatment compared with 18.6–21 deaths per 100 person-years with quetiapine and valproic acid. In addition, we previously showed (7) that the absolute mortality risk over 12 months in patients taking atypical antipsychotics was 4.8% higher than in those not taking medication, which corresponds to a number needed to harm of 20.8. Therefore, if atypical antipsychotics are to be prescribed, then they should be used in conjunction with a risk-benefit approach taking into account the efficacy and safety evidence base for the agents under consideration.Ann Arbor, MichiganLos AngelesThe authors' disclosures accompany the original article.Accepted for publication in March 2012.References1. Kales HC , Kim HM , Zivin K , Valenstein M , Seyfried LS , Chiang C , Cunningham F , Schneider LS , Blow FC: Risk of mortality among individual antipsychotics in patients with dementia. Am J Psychiatry 2012; 169:71–79Link, Google Scholar2. Huybrechts KF , Gerhard T , Crystal S , Olfson M , Avorn J , Levin R , Lucas JA , Scheeweiss S: Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population-based cohort study. BMJ 2012; 344:e977Crossref, Medline, Google Scholar3. Nasrallah HA , White T , Nasrallah AT: Lower mortality in geriatric patients receiving risperidone and olanzapine versus halo-peridol: a preliminary analysis of retrospective data. Am J Geriatr Psychiatry 2004; 12:437–439Crossref, Medline, Google Scholar4. Blazer DG: Comment on Nasrallah et al: lower mortality in geriatric patients receiving risperidone and olanzapine versus haloperidol. Am J Geriatr Psychiatry 2004; 12:658–659Medline, Google Scholar5. Kim HM , Chiang C , Kales HC: After the black box warning: predictors of psychotropic treatment choices for older patients with dementia. Psychiatr Serv 2011; 62:1207–1214Link, Google Scholar6. Schneider LS , Dagerman KS , Insel P: Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005; 294:1934–1943Crossref, Medline, Google Scholar7. Kales HC , Valenstein M , Kim HM , McCarthy J , Ganoczy D , Cunningham F , Blow F: Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications. Am J Psychiatry 2007; 164:1568–1576Link, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 169Issue 6 June 2012Pages 664-665 Metrics PDF download History Accepted 1 March 2012 Published online 1 June 2012 Published in print 1 June 2012" @default.
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