Antipsychotics as Chemical Restraints: care or constraint in nursing homes?

by Elizabeth Curley

The Washington Post recently published an article on lobbying pressure to loosen regulations of prescribing and monitoring of antipsychotics within nursing homes, often for behavioral control instead of medical need. This article effectively summarizes a regulatory tug-of-war and the issues of chemical restraints in nursing homes. 

One facet of this issue can be pinned on nursing home regulations and how policy passively endorses or obscures issues of overprescribing or inappropriate prescribing. The up-close, lived version of these issues is much harder to look at. 

Throughout the 2010s, there was an invigorated attention to the lived experiences of residents in nursing homes, as NPR and Human Rights Watch published pieces on issues of overmedication. These stories describe older adults who are extremely sedated; who have been placed on multiple antipsychotics at a time, calling out for help, slumped over in wheelchairs, mumbling to themselves, sleeping all of the time, with only a tenuous ability to refuse without being threatened with removal from the home. Families of survivors describe personality-erased and silenced loved-ones. 

Real people, older adults, who have been entrusted to nursing homes for consistent care are facing a real crisis of compassion. One international review from 2019 found that staff self-reported perpetrating abuse at alarming rates: ~64% of staff admitted to committing some form of abuse against residents. A 2021 review echoed these findings, highlighting that in large U.S. samples, nearly half (44%) of residents reported abuse and 95% reported neglect or witnessing neglect of others. Compounding this, is the problem of over- and mis-medication of these same vulnerable adults. 

Antipsychotics were born from a wandering path of utility, like many psychotropic medications such as antidepressants which trace back to drugs originally developed to treat tuberculosis. Originally developed as an antihistamine in the 1940s, Chlorpromazine became the early foundation of the antipsychotics class because a surgeon (Henri Laborit) experimented with the drug in the early 1950s to produce “artificial hibernation”. The therapeutic benefit of this drug was offered due to the profound sleepy, apathetic, and emotionally blunted state it produced - an effect that Laborit himself described as a "pharmacological lobotomy”. 

Despite progressions in medication development, more than 70 years later, those same core mechanisms persist in our current antipsychotics: emotional dampening, sedation, and apathy. These drugs are prescribed to nursing home residents at an alarming rate: more than one in five (21.3%) facility residents are prescribed an antipsychotic. This 21% was the result of an increase of almost 5% from the previous quarter (Q3 2023) despite a decrease in the number of facilities reporting their prescribing data. This is more than 10 times higher than the percentage of residents with a clinical diagnosis that would medically justify the medications for intended use, such as schizophrenia. 

As it is in many systems, these issues are made worse by the built-in wool over our eyes; system reporting and oversight is often limited or inaccessible to the public. OIG found that nursing homes failed to report 43% of falls with major injury and hospitalization among Medicare-enrolled residents. Certain states had higher rates of non-reporting, with Florida, Arizona, California and a few others holding steady at around 51-64% unreported. Specific state reports and audits are available for the conditions and compliance of nursing homes (especially those that receive Medicaid); one report for North Carolina found that 68% of nursing homes had late inspections from 2021 to 2023. 

Despite federal legislation requiring inspections every 15 months (or every 6 months for higher-risk facilities) and the approximately $9.36 billion in Medicaid funds the facilities received from 2019 to 2023, the majority of facilities were not inspected on time. These delayed inspections allowed serious deficiencies including abuse, neglect, failure to treat residents with dignity, medication mishandling, and inaccurate care plans after falls or ulcers, to go undetected and uncorrected for extended periods. 

These are the facilities, across the United States, we trust to accurately report and properly assess and deliver antipsychotic medication in appropriate circumstances or dosage. In many such cases, “medication mishandling” has involved the routine use of antipsychotics - historically known as major tranquilizers - whose true impact is far more sedative and behavior-controlling than therapeutic. 

In March of 2026, the Office of Inspector General (OIG) completed an analysis on 40 focused Centers for Medicare & Medicaid Services (CMS) inspections across the country between 2018 and 2021. They found that nursing homes routinely administered antipsychotics to residents with dementia for staff convenience and behavior control, not legitimate medical need. Staff described the drugs as the “fastest and easiest” option, using them to quiet nighttime yelling, enforcing mobility compliance, or manage seemingly harmless actions like carrying a baby doll or signaling for the bathroom. These represent textbook chemical restraints, violating Medicare rules that residents must be free from drugs not required for medical symptoms. The sedative effect is treated as a quick fix for staffing shortages rather than addressing root causes like untreated infections or pain. 

The companion report from OIG reveals an even darker layer of financial exploitation and regulatory gaming: nursing homes systemically added false or inflated schizophrenia diagnoses to resident records to mask antipsychotic misuse and artificially inflate their Medicare star ratings. 

Residents with a schizophrenia diagnosis are excluded from the public antipsychotic-use quality measure, this loophole allows facilities to slash their reported numbers (one home dropped from over 80% to 5%) and avoid scrutiny from pharmacists and surveyors. Medical directors signed off without evaluations, electronic alerts and company-wide policies pushed the changes, families were often never told. 

The result was unnecessary, high-dose antipsychotics continued for years, exposing frail elderly residents to the FDA’s boxed warning of increased death risk while shielding the facilities from accountability and preserving reimbursement tied to high ratings. Both OIG reports demonstrate that overprescribing isn’t accidental. 

Overprescribing is a system of chemical social control that prioritizes facility convenience and profit margins over the safety of their residents.

The perceived advantage of using these drugs to control behavior is argued to be that residents, if they become violent, could be required to be removed from the care facility. The broad reality is that our elderly population (especially those in long-term care facilities) is poorly treated and insufficiently protected. It is also true that as time weighs on our minds and bodies, people also suffer from aggression and personality changes. These shifts often stem from infection, cognitive decline (from Alzheimer's to more mild conditions that still cause disorientation) and the profound grief of lost autonomy. 

We may not need revolutionary new drugs or impossible budgets. We do however need enforceable rules that treat antipsychotics as a last resort with clear clinical criteria and mandatory assessment of root causes. We need minimum staffing standards paired with serious training on the unique challenges of aging. The payment systems must reward genuine, realistic care rather than low labor costs and artificially clean quality scores. 

As a society, we must also expand our hope horizons. Real world successes already exist. 
Models like the Green House Project show that small-home, person-centered care can improve quality of life while reducing Medicaid and Medicare costs. Approaches like the GuideStar model have reported up to a 68% reduction in antipsychotic use for people with dementia. 

These approaches center human connection, meaningful activity, and care that sees the person behind the behavior - what many thought care facilities were providing their elders to begin with. 

As long as the financial structure rewards low labor costs, higher margins, or better looking quality scores without fully capturing harm, there will be pressure on the system to cut corners. Not every for-profit nursing home is abusive, but the incentive structure can make misuse of antipsychotics more likely without strong regulation, transparency, and enforcement. 

Although there is no single corrective action to be taken, a dual approach of restructuring what is rewarded within the current system and exploring alternative models can push us to expand our understanding of the way that care can look for all of us in our late years. 

If we cannot find a way to preserve dignity, safety, and authentic care for older adults within nursing home jurisdiction, we will continue a pattern of chemical restraint; one that began with an experimentation in artificial hibernation, yet persists today as routine behavioral control. Until then, we are not caring for our elders, we are simply quieting them.