Pragmatic trials may help to identify effective strategies to reduce nursing home antipsychotic medication use.

Despite widespread agreement that nursing homes' use of antipsychotic medications for residents without specific psychiatric diagnoses is a marker of poor quality of care, prevalence remains high. Additionally, variation suggests continued opportunity to improve care even in countries, like the United States, that have long-standing policies designed to decrease antipsychotic medication use. In a recent Israel Journal of Health Policy Research article, Frankenthal et al. presented results linking increased antipsychotic medication use prevalence in Tel Aviv nursing homes with facility characteristics, including some that "undermine quality of care," and called for increased national focus on this area. While we agree with the authors that government focus can help to decrease antipsychotic medication use, experience in the United States shows that such efforts may not be sufficient: we present data showing significant variation among United States nursing homes' antipsychotic medication use prevalence after more than ten years of national warnings and programs. This suggests that United States nursing home clinicians and caregivers continue to need effective non-pharmacologic interventions to substitute for antipsychotic medications. We suggest expanded use of cluster-randomized trials to test strategies to withdraw residents from antipsychotic medications and to implement alternate, non-pharmacological approaches for addressing the behavioral and psychological symptoms of dementia.