Potentially inappropriate use of antipsychotics in community-dwelling adults with dementia more common in those with low income.

ED FROM Puyat JH, Law MR, Wong ST, et al. The essential and potentially inappropriate use of antipsychotics across income groups: an analysis of linked administrative data. Can J Psychiatry 2012;57:488–95. Correspondence to: Puyat JH, School of Population and Public Health, University of British Columbia, 201–2206 East Mall, Vancouver, Canada BC V6T 1Z3; jpuyat@ interchange.ubc.ca Sources of funding: BCMOHS, Canadian Health Services Research Foundation; Alberta Heritage Foundation for Medical Research, Canadian Institutes of Health Research. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/eb-2012-101180). CO M M EN TA RY Puyat and colleagues examine the relationship between antipsychotic use and household income among community-dwelling and institutionalised patients. Based on analyses of linked health, pharmaceutical use and income data from British Columbia from 2004 to 2005, they found income-related differences in essential antipsychotic use for schizophrenia or bipolar disorder, and inappropriate antipsychotic use among community-dwelling older adults. In both cases, low-income individuals were at higher risk of poorer prescribing. Given the paucity of data regarding income-related effects on inappropriate medication use, these data will likely receive attention. However, these provocative findings should be interpreted in proper context. First, the authors estimate antipsychotic prescribing in long-term care to be 56%, a finding that is not replicated in the literature. A point-prevalence study of Ontario nursing homes reported that 32.4% of residents received antipsychotics in 2003. Most published studies report similar findings. Second, Mor et al report that low resource nursing homes serve predominantly poor communities and have higher levels of antipsychotic use. Complicated interactions between community poverty and healthcare facility resources likely explain much of the relationship between prescribing and household income in community mental health and primary care clinics as well. These factors are also likely to be related to ‘prescribing cultures’, institutional forces that drive prescribing, independent of clinical appropriateness. This phenomenon defines the patient risk factor as exposure to healthcare facilities with high levels of inappropriate prescribing. While primarily described in long-term care, this phenomenon likely exists in community care settings as well. Taken together, complex relationships between household income, community poverty and healthcare facility resources likely contribute to inappropriate care. Improvements in prescribing need to focus beyond payment and public medication coverage to also address the context of care available to impoverished patients.