Appropriate Use of Psychotropic Medications

Psychotropic medications are drugs that affect the brain’s activities associated with mental processes and behaviors. These medications may also be referred to as psychoactive drugs and are generally prescribed to treat mental illnesses, including anxiety, depression, psychosis and schizophrenia. 

The types of psychoactive drugs include:

• Anticonvulsants: Also called antiepileptics, these medications are often used to reduce the frequency and severity of seizures. They are also used in the treatment of mental illnesses, including bipolar disorder or borderline personality disorder. 
• Antidepressants: These medications are prescribed to treat depression, usually by increasing the availability of certain chemical messengers (neurotransmitters) in the brain.
• Antipsychotics: Medications used to manage psychosis, primarily in people with schizophrenia. Antipsychotics are also used to treat other psychotic disorders and as an adjunct in the treatment of bipolar disorder. 
• Anxiolytics: Also called anti-anxiety drugs, these medications are used to treat anxiety, mild behavioral agitation and insomnia. They may also be used as adjunctive treatment for depression and panic disorder. 
• Sedatives and hypnotics: These medications are used to induce or sustain sleep by increasing drowsiness and decreasing motor activity. The difference between a sedative and a hypnotic is generally the dose prescribed, with higher doses of a medication used to achieve hypnotic effects and lower doses for sedation or to relieve anxiety.  

In nursing facilities (NFs), there has been a tremendous focus on antipsychotic medications – often prescribed inappropriately to treat the behavioral and psychological symptoms of behavioral and psychological symptoms of dementia (BPSD). Since 2014, there have been significant efforts to reduce the inappropriate use of antipsychotics. However, recent data suggest that as antipsychotic use has decreased in NFs, the use of other psychotropic medications has increased. The U.S. Department of Health and Human Services Office of the Inspector General’s report “Long-Term Trends of Psychotropic Drug Use in Nursing Homes (PDF)" suggests that up to 80% of Medicare beneficiaries living in a NF had been prescribed a psychotropic medication. 

While psychotropic medications are important tools for treating mental illness, they are not without risk, even when prescribed appropriately. When prescribed inappropriately, the risks will generally outweigh the benefits of these medications. When prescribed appropriately, psychotropic medications can have a positive impact on a person’s quality of life and the quality of care they receive in a NF. 

For example, all antipsychotics carry a black box warning required by the U.S. Food and Drug Administration (FDA) stating that they are associated with increased rates of stroke and death in older adults with dementia. In 2023, the FDA approved the use of the antipsychotic brexpiprazole to treat agitation related to Alzheimer’s disease. Despite this new indication for use, brexpiprazole still carries the black box warning. The physician must consider the risks versus benefits before prescribing this medication, and non-pharmacological interventions should be the first line of treatment in these situations. 

NFs must develop well-defined processes for monitoring the use of psychotropic medications, promoting gradual dose reductions when indicated and preventing the inappropriate prescribing of these drugs. Each person receiving a psychotropic medication should have ongoing monitoring for targeted behaviors and potential adverse reactions. Some medications may require specific monitoring processes, including laboratory or other diagnostic testing. 

Non-pharmacological interventions should be considered as part of any behavioral management program. This may require changes in facility policies, procedures and nursing care practices. All staff should be trained on behavior management techniques. 

Best Practices

Resources Created by HHS

• Improving Dementia Care: Strategies for Pharmacists in Long-Term Care Facilities (PDF) was developed as a resource for consultant pharmacists as they work with prescribers to reduce the use of antipsychotic medications in nursing home residents.
• Improving Dementia Care: The Strategies for Prescribers (PDF) is a resource for physicians and other professionals who prescribe medications for nursing home residents. This brochure includes strategies prescribers can utilize to improve dementia care and reduce the use of antipsychotic medications.
• Improving Dementia Care: The Role of Prescribers (PDF) was developed as a resource for physicians, PA-Cs and Nurse Practitioners who work with nursing home residents. These professionals play a key role in the efforts to reduce the inappropriate use of antipsychotic medications in nursing homes.
• Limiting the Use of PRN Psychotropic Medications (PDF) provides prescribers and nursing home staff with helpful information regarding the use of psychotropic medications on an as needed basis.
• Evidence-based Best Practice for Antipsychotic Medications (PDF) provides evidence-based best practice guidelines for addressing management of antipsychotic medication use in the long-term care setting.
• View this HHS-produced video about Reducing Antipsychotics in Nursing Homes with Dr. Allen Power.

Resources from the Centers for Medicare & Medicaid Services

• The National Partnership to Improve Dementia Care in Nursing Homes works to reduce the use of antipsychotic medications when not clinically indicated.
• Hand in Hand: A Training Series for Nursing Homes Toolkit addresses the need for nurse aides’ annual in-service training to care for NF residents with dementia.
• The Adverse Drug Event Trigger Tool (PDF) was developed for use by surveyors but can be used to help NFs identify situations that may indicate an adverse drug event has occurred.
• Survey Resources: LTC Survey Pathways are used by surveyors to evaluate specific areas of care, including medication administration, unnecessary medications and medication storage. These pathways can also be used by NFs to evaluate their systems. (Note: Scroll down the page to Downloads and choose Survey Resources, then choose a pathway from the ZIP file.)  

Resources from Other Organizations

• American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults provides access to the 2023 revision to the Beers Criteria and related resources. (Note: Access to some resources on this website require purchase.)  
• Sane Use of Psychotropic Medications (PDF) addresses behaviors, altered mental status and treatment options.
• Maintenance Treatment of Major Depression in Old Age addresses the need for practical strategies to manage depression in older people to avoid death or recurrence of depression and disability.
• Older Adults and Depression presents information and resources regarding depression in people who are aging.
• Deprescribing Guidelines and Algorithms are evidence-based resources that can assist prescribers to carry out safe deprescribing of specific medication classes, including antipsychotics and benzodiazepines. 
• Key Guidelines for Gradual Dosage Reductions of Psychotropic Medications identifies the critical steps and considerations for implementing gradual dose reductions in the NF. 
• Choosing Wisely and The American Geriatrics Society (PDF) identifies 10 treatments and tests that may not be effective and have a higher risk profile in older adults, including using antipsychotics to treat BPSD and the use of sedatives or hypnotics in older adults as a first-line treatment for insomnia, agitation or delirium. 
• Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) is a collection of resources and tools help caregivers manage uncharacteristic behaviors while reducing the inappropriate use of antipsychotics in people with dementia.