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Over the past decade or so, atypical antipsychotic use has exploded, for both FDA approved indications and off-label treatments.

Due to their inhibition of both serotonin and norepinephrine reuptake, the SNRIs venlafaxine (Effexor) and duloxetine (Cymbalta) have been billed as possessing an advantage over SSRIs.

While drug companies have been working hard to come up with new options for the treatment of dementia, there have been no new FDA approvals since memantine (Namenda) hit the scene in 2003.

Most psychiatrists rely on the Folstein Mini Mental State Exam for a rapid, office-based neuropsychological assessment. But the MMSE has some serious limitations. A hot new test, called the Montreal Cognitive Assessment (MoCA) appears to work much better.

In 2005, the FDA issued a health advisory saying that antipsychotics appear to increase the risk of death in elderly patients with dementia. That advisory was based on data from placebo-controlled trials of antipsychotics conducted by industry. Now, a new study based on a completely different, and much larger, dataset, appears to confirm these dangers.

It has now been a full ten years since the first of the second-generation cholinesterase inhibitors (CIs), Aricept (donepezil) was approved for Alzheimer’s dementia.

A 70-year old man comes into your office and asks: “Doctor, I keep misplacing my keys-am I getting Alzheimer’s?” You detect the note of anxiety in his voice, and you want to give an answer, and soon.

Why don’t we start with the issue of agitation? The question in many psychiatrists’ minds is how seriously we should take the FDA advisory about the dangers of atypical antipsychotics?