Overdiagnosis of schizophrenia in nursing homes is rampant, especially for Black residents.

By Judith Garber | October 24, 2021

Overuse of antipsychotic medications is a long-standing problem among nursing home residents with dementia. Antipsychotic drugs in older adults can lead to falls, hospitalizations, and death. Despite the clear risks, these drugs are often given to nursing home residents with dementia to keep them subdued, especially if staffing levels at the institution are low.

There have been many attempts by the US government to solve this problem. As early as 1987, the Centers for Medicare and Medicaid Services (CMS) banned the use of “chemical restraints” in nursing homes that were not required to treat medical symptoms. In 2008, the US Food and Drug Administration put a black box warning on all antipsychotics to inform health care professionals that elderly patients with dementia taking antipsychotics are at an increased risk of death, and to clarify that these drugs are not supposed to be used to treat dementia.

In 2012, CMS created the National Partnership to Improve Dementia Care in Nursing Homes, with a central goal of reducing the use of antipsychotics for dementia in nursing homes. As part of this initiative, CMS started reporting nursing homes’ rates of antipsychotic drug use. However, nursing homes are not required to report use of antipsychotic drugs for patients diagnosed with schizophrenia, Huntington’s Disease, or Tourette’s Syndrome, giving these institutions a potential loophole to the rule.

Although the reported rate of antipsychotic use has declined since 2012, this decline is in part due to a rise in schizophrenia diagnoses. A recent New York Times investigation found that the proportion of nursing home residents diagnosed with schizophrenia increased by 70% since 2012. An estimated one-third of these patients diagnosed with schizophrenia in 2018 did not have a record in Medicare claims of being treated for the condition, indicating these may just be false diagnoses to justify use of antipsychotics. Typically, schizophrenia is diagnosed before age 40, not later in life.

“Today, one in nine residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people.”
Katie Thomas, Robert Gebeloff and Jessica Silver-Greenberg, The New York Times

While CMS reports about 15% of nursing home residents taking antipsychotics, when including diagnoses of schizophrenia, Huntington’s Disease, or Tourette’s Syndrome, more than 21% of residents are taking them, The New York Times found.

Overdiagnosis of schizophrenia appears to be more prevalent than for Black nursing home residents. A recent study from researchers at the School of Public Health at Brown University found that after 2012, Black nursing home residents with dementia were 1.7 times as likely to be diagnosed with schizophrenia compared to nonblack residents.

One reason for this pattern may be differences in quality of care and staffing between nursing homes serving older adults of different race/ethnicities. Covid-19 made it even these disparities even more clear; nursing homes serving more Black and Latinx residents were more likely to have at least one Covid-19 case. In New York state for example, 84% of nursing homes with at least a quarter of Black and Latinx residents had at least one Covid-19 case, while only 33% of mostly-white nursing homes had a Covid-19 case.

Similarly, recent research on low-value care in US health systems by Dr. Ishani Ganguli and colleagues found that health systems caring for more patients of color had greater rates of overuse. Use of antipsychotics for dementia was one of the most prevalent overused services measured in this study, with 23.5% of Medicare beneficiaries with dementia (but without severe mental illness) receiving antipsychotic medications in 2016-2017. However, in some health systems, more than 50% of beneficiaries with dementia received antipsychotics.

The overuse of antipsychotics and overdiagnoses of severe mental illness make it clear that reporting requirements are not enough to fix the widespread quality and staffing issues at nursing homes. Although the 2012 policy did not single out nursing homes serving Black residents, the loophole created another racial divide– a disparity in overdiagnosis as well as overmedication. We need more oversight and resources for nursing homes, particularly those serving people of color, to get at the root of the problem. Otherwise the overuse of antipsychotics and other drugs chemical restraints will remain prevalent in these settings, putting the lives and health of nursing home residents at risk.

To eliminate medication overload, serious cultural, educational, and policy changes are needed. This action plan offers recommendations for policymakers, health care institutions, clinicians, and patients across five key categories to reduce harm from multiple medication use. Suggested Citation: Eliminating medication overload: A national action plan. Working Group on Medication Overload. Brookline, MA: The Lown Institute, 2020. DOI: https://doi.org/10.46241/LI.YLBW4885

Pharmaceutical marketing is a significant factor in the growing public health crisis of medication overload, which puts millions of older adults at risk of preventable harm and premature death. This issue brief provides recommendations to reduce pharmaceutical industry influence by limiting pharma sales rep visits to clinicians and direct-to-consumer advertising.

This issue brief provides recommendations for clinical practice guidelines and electronic health records that would give clinicians the information they need to appropriately prescribe and deprescribe.