The uncomfortable truth about antipsychotic use: Are we judging from the sidelines?

Every few months, another study lands condemning the rates of antipsychotic use in aged care. This week was no different. Researchers again pointed to “persistently high” prescribing rates, calling for stronger oversight, tighter regulation, and more staff training to curb the use of psychotropics and antidepressants among residents.

The message is clear: we must do better.

But maybe the question isn’t whether providers want to reduce medication use — most do — but whether they actually can, given the current reality of aged care.

Between idealism and reality

It’s easy to call for non-pharmacological interventions when you’re not the one standing in the corridor with three residents yelling, another attempting to strike someone, and a nurse trying to de-escalate with no support worker in sight.

Because that’s the reality in many homes today.

• Ratios are tight — sometimes dangerously so.
  
• Training in dementia behaviour management is inconsistent, especially for agency or new staff.
  
• Lifestyle budgets have been slashed or reallocated to “essential” care.
  
• Allied health and behaviour specialists are stretched across multiple sites.
  

So when a GP, clinical lead, or nurse chooses to use a psychotropic, is it neglect, or a last resort in a system that’s already on its knees?

The ethical paradox

There’s an ethical tension here that few outside the floor really understand.

Every leader in aged care wants to preserve dignity, autonomy, and a restraint-free environment. But what happens when a resident’s “responsive behaviour” (to use the clinical euphemism) becomes violent, unpredictable, or distressing to others?

Medication, in those moments, isn’t a shortcut – it’s a shield. It can protect the resident themselves from harm. It can protect co-residents from being hit or bitten. It can protect a carer from yet another traumatic shift.

When there’s no time, no staff, and no safe space to calm someone, the ideal interventions simply aren’t accessible.

The research gap: context

It’s worth asking: how many researchers and policymakers calling for lower medication use have actually worked in care (or at least in the thick of it)?

How many have seen the chaos of sundowning hours, the heartbreak of a dementia patient who no longer recognises their partner, or the fear in the eyes of a care worker who’s been hit for the third time this week?

It’s easy to cite guidelines from a desk. It’s harder to deliver person-centred care when the system gives you one set of hands for ten residents with complex needs.

The leadership question

This isn’t about defending medication misuse. It’s about acknowledging complexity.

As leaders, we can’t shy away from the uncomfortable truth: in a chronically understaffed, under-resourced system, sometimes medication isn’t the easy way out, it’s the only way through.

But we also can’t accept that as the endpoint. We need to use this moment to push for structural reform:

• Ratios that reflect reality, not wishful policy.
  
• Continuous training in dementia-specific care and de-escalation.
  
• Funding models that reward quality of life, not just clinical compliance.
  
• Investment in behavioural specialists and multidisciplinary teams.
  

Until those are in place, the rhetoric of “just reduce psychotropics” risks being not only naïve — but dangerous.

Final thought

Maybe the next time another report lands, we shouldn’t ask why are antipsychotic rates still high?

We should ask why haven’t we given providers the tools, teams, and time to do any better?

Because behind every data point is a story of someone doing their best – often in impossible circumstances – to keep people safe.