Issue 003, 2015 q4

Misuse of antipsychotics in workers’ compensation patients

BY Reema Hammoud PharmD, BCPS, Director, Clinical Pharmacy, Sedgwick

Antipsychotics are medications used for the treatment of acute and chronic psychosis and other psychotic conditions. Besides their defined indication by the Food and Drug Administration, antipsychotics are often used and misused for off-label conditions such as depression, post-traumatic stress disorder and insomnia. Like all other medications, they have their fair share of side effects and drug interactions. 


According to a 2014 drug trends report, antipsychotics accounted for 2.3% of the total drug cost for workers’ compensation claims, with a 2.0% increase in the average cost per prescription in 2014 compared to 2013. Not only are these medications expensive, but their misuse is growing.1

In the injury claims we have seen at Sedgwick, these drugs are not always prescribed by a psychiatrist or a behavioral health expert, and patients often do not receive follow-up by a multi-disciplinary team. Antipsychotics are usually prescribed by primary care physicians who are not trained in behavioral management and not familiar with the side effects and drug interactions.A lot of adverse events are often overlooked and drug interactions are not closely monitored.3 Just recently, Sedgwick’s staff pharmacists were referred to a case in which the primary care provider was prescribing his patient anticonvulsants as mood stabilizers, antidepressants for depression and sleep, and antipsychotics for depression and insomnia. The patient was also being followed by a pain specialist who was prescribing opioids, anxiolytics and stimulants. Additionally, the physicians were not exchanging progress notes and the patient was unaware of the dangerous combination he was taking.

This patient was being prescribed medications to help with the side effects of his other medications. Psychosis was not a documented diagnosis for him, yet he was taking two antipsychotic medications to help with sleep and depression. A psychiatric evaluation was never part of the patient’s progress notes nor was there a risk assessment in the medical record to determine his risk for drug abuse or overdose. After one of Sedgwick’s staff pharmacists spoke with both providers, both of the psychotropic medications were discontinued and the patient was referred to a psychiatrist to help manage his depression and anxiety, which were not related to his workers’ compensation injury.

Antipsychotics are generally not recommended for workers’ compensation injuries. While there is some data to support use for treatment-resistant depression, there is insufficient data to support their use as standalone therapy. The patient population that we help monitor should rarely be on any psychotropic medications, as studies show that the use of these agents in the treatment of workers’ compensation injuries offers little to no benefit in functional improvement or quality of life.4, 5

Based on our experience with these types of cases, the use of antipsychotic medications often does more harm than good for the injured employee. Risk managers must evaluate the behavioral health and prescription drug management components of their claims and healthcare programs. A team of physicians, pharmacists and specially trained clinicians must be systematically connected with the claims administration professionals and their systems in order to address life-threatening situations quickly. Behavioral health and pharmacy solutions prompt prevention of these types of dangerous situations and provide key intervention.

Technology interfaces must be equipped to systematically sound the alarm and the first responders must include a multi-disciplinary team of medical experts. Sedgwick’s pharmacy clinical review program includes point-of-sale interventions managed by our nurses who review medications prior to dispensing. Drug alerts interface with our proprietary claims management system and when an alert is received, our clinical team will confirm it is the correct treatment for the injury, work with the physician to make any necessary prescription changes – and ultimately ensure the injured employee’s safety.



2. Spielmans GI, Berman MI, Linardatos E, Rosenlicht NZ, Perry A, Tsai AC. Adjunctive atypical antipsychotic treatment for major depressive disorder: a meta-analysis of depression, quality of life, and safety outcomes. PLoS Med. 2013 Mar; 10 (3):e1001403. doi: 10.1371/journal.pmed.1001403.

3. Jin H, Shih PA, Golshan S, Mudaliar S, Henry R, Glorioso DK, Arndt S, Kraemer HC, Jeste DV. Comparison of longer-term safety and effectiveness of 4 atypical antipsychotics in patients over age 40: a trial using equipoise-stratified randomization. J Clin Psychiatry. 2013 Jan; 74(1):10-8. doi: 10.4088/JCP.12m08001.

4. Hellerstein DJ, “Aripiprazole as an Adjunctive Treatment for Refractory Major Depression,” Prog Neuropsychopharmacol Biol Psychiatry, 2004, 28(8):1347-8. NCBI website – PubMed 15588762.

5. Ketter TA, Wang PW, Chandler RA, et al, “Adjunctive Aripiprazole in Treatment-Resistant Bipolar Depression,” Ann Clin Psychiatry, 2006, 18(3):169-72. NCBI website – PubMed 16923655.

Issue 003, 2015 q4

Looking back

Issue 003, 2015 q4

Edging up

Short takes on emerging industry issues – from EDRs to ICD codes and MSAs