In Reply We did not claim in our Viewpoint, nor do we believe, that the National Partnership to Improve Dementia Care in Nursing Homes has been the sole cause of the decline in antipsychotic use observed among nursing home residents over the past 5 years.¹ What we did claim is that the evidence suggests that it played a significant role, and that, without it, progress would have been slower and less steady. In their letters, Dr Gillick and Dr Westbury raise some important contextual issues relevant to the findings reported in our Viewpoint. Gillick describes the marketing efforts of pharmaceutical manufacturers to promote non–FDA-approved (off-label) use of atypical antipsychotics and the large financial settlements that have been paid to federal and state governments for engaging in off-label promotion. Pharmaceutical marketing activities in nursing homes were quite common prior to the launch of the National Partnership to Improve Dementia Care in Nursing Homes.² In the 2011 report of the Office of Inspector General, “Medicare Atypical Drug Claims for Elderly Nursing Home Residents,”³ the aggressive marketing efforts of the pharmaceutical industry were highlighted. However, although it is possible that large financial settlements against manufacturers and the cessation of illegal marketing practices contributed to reductions in off-label antipsychotic prescribing, evidence supporting this specific association is not available.⁴

在答复中，我们既没有提出观点，也没有相信，在过去5年中，全国养老院改善痴呆症护理的国家合作伙伴关系一直是引起抗精神病药使用下降的唯一原因。^1个我们所做的是，有证据表明，它发挥了重要作用，没有它，进展将变得缓慢而不稳定。Gillick博士和Westbury博士在信中提出了一些重要的背景问题，这些问题与我们观点中报告的发现有关。吉利克（Gillick）介绍了药品制造商在市场营销方面的努力，以推广未经FDA批准（非标签）使用的非典型抗精神病药，以及为参与标签外促销而支付给联邦和州政府的大量财务结算。在建立“改善护理院中的痴呆症国家合作计划”之前，在护理院中开展药品营销活动非常普遍。^2个在监察长办公室2011年的报告“针对老年人疗养院居民的医疗保险非典型药物索赔”中，³强调了制药业的积极营销努力。但是，尽管有可能针对制造商进行大规模的财务和解以及停止非法的营销手法导致标签外抗精神病药处方的减少，但尚无支持这种特定关联的证据。⁴