Choosing Wisely

Arif Ahmed's picture

On 24th October 2016 The Academy of Royal Colleges published a list of 40 interventions which have little or no benefit for patients, as part of the Choosing Wisely campaign.

The list was produced following consultation with experts from 11 medical specialties and patient groups. A similar list has already been published in Canada ( and the USA (

The top 4 recommendations from The Royal College of Psychiatrists are:

1) In the treatment of depression, if an antidepressant has been prescribed within the therapeutic range for two months with little or no response, it should be reviewed and changed or another medication added, which will work in parallel with the initial drug that was prescribed.

2) When adults with schizophrenia are introduced to treatment with long-term anti-psychotic medication, the benefits and harm of taking oral medication compared to long-acting depot injections should be discussed with all relevant parties

3) Women who are planning a pregnancy or may be pregnant should not be prescribed valproate for mental disorders except where there is treatment resistance and/or very high risk clinical situations

4) When a diagnosis of psychosis is made, CT or MRI head scans should only be used for specific indications where there are signs or symptoms suggestive of neurological problems

It is encouraging that the recommendations are in line with the principles of sustainability in mental health. Apart from the obvious focus on waste and improving value, the empowerment aspect of the Choosing Wisely project is arguably the most beneficial. Patients are empowered and encouraged to question clinicians about risks and benefits of treatments and investigations and to be able to collaborate on important decisions. Clinicians likewise can be more confident in only ordering truly necessary investigations.

The top 4 is likely to stimulate discussion and debate from those involved in mental health settings, which again I think is a positive thing. Getting us to reflect upon the things we do in our daily practice and consider the benefit to service users and carers is really important. There is a plan over the coming months to engage the various faculties of the college to come up with their own top recommendations.

Do you agree with the top 4? Would you have chosen other recommendations?


Choosing Wisely

Shiva Marjani's picture

"Do not routinely prescribe high-dose or combination antipsychotic treatment strategies in the treatment of schizophrenia."

Isn't this more important than option 2?
Depending on who finally should Choose Wisely, Doctor or Patient?


I think that is also an

Arif Ahmed's picture

I think that is also an important one Shiva. Likewise one could argue about the huge problem of antipsychotic use in those with dementia. With the nature of patients acutely unwell in psychiatry, we often make choices in their 'best interests', but that also needs to be a wise choice in the widest sense of the meaning.


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