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When something isn't working, prescribers have the unfortunate tendency to add on rather than to reconsider.

Polypharmacy In Psychiatry: A Review

Sanjay Kukreja, M.B.B.S., F.C.L.R,* Gurvinder Kalra, M.D,** Nilesh Shah, M.D., D.N.B.,*** and Amresh Shrivastava, MD, MRCPsych****

Abstract

Psychiatric polypharmacy refers to the prescription of two or more psychiatric medications concurrently to a patient. It can be categorised as same-class, multi-class, adjunctive, augmentation and total polypharmacy. Despite advances in psychopharmacology and a better understanding of the principles of therapeutics, its practice is increasing rapidly. The prevalence of polypharmacy in psychiatry varies between 13%-90%. There are various clinical and pharmaco-economic factors associated with it. Dealing with polypharmacy requires an understanding of its associated factors. Education, guidelines and algorithms for the appropriate management of various conditions are effective ways to avoid irrational polypharmacy.

Keywords: Drug combinations, Multiple medications, Polypharmacy, Psychopharmacology

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Introduction

The field of clinical psychiatry is challenging and physicians have been exploring methods to deal with complex situations. Some of these conditions present with life-threatening concerns, while others present with patients becoming unresponsive and resistant to treatment. Polypharmacy has been one method which physicians have been using in difficult circumstances since a long time; however, its appropriateness has of–late come under scrutiny.

Polypharmacy is the use of multiple medications for the treatment of a patient's medical condition. The basis for this definition is solely quantitative and does not take into account the clinical pertinence of the use of these medications (for example, the presence of multiple diseases) or the adequacy of the proposed therapeutic regimen (Rollason and Vogt, 2003[41]). The term polypharmacy suggests that more medication is being used than is ‘clinically indicated.’ The number of medications that constitute polypharmacy however, has not been defined in the available literature (Hidalgo et al., 1997[24]; Jörgensen et al., 2001[17]; Linjakumpu et al., 2002[23]).

The commonly used definition of psychiatric polypharmacy is the use of two or more psychiatric medications in the same patient, (NASMHPD Technical Report, 2001[32]) or using two or more medications (of the same chemical class or same pharmacologic actions) to treat the same condition (Kingsbury et al., 2001[20]).

Types of Polypharmacy

Due to the increasing prevalence and complexity in psychiatric polypharmacy, it is categorised as follows by the National Association of State Mental Health Programme Directors (NASMHPD) (NASMHPD Technical Report, 2001[32]):

 Same-Class Polypharmacy refers to the use of more than one medication from the same class (e.g. use of two selective serotonin reuptake inhibitors in a case of depression).

Multi-Class Polypharmacy is the use of full therapeutic doses of more than one medication from different classes for the same symptom cluster (e.g. use of valproate along with an atypical antipsychotic, such as olanzapine, for treatment of mania).

Use of one medication to treat the side effects of another medication from a different class, is described as Adjunctive Polypharmacy (e.g. using trazodone for insomnia caused by bupropion).

Augmentation Polypharmacy refers to the use of one medication at a lower than normal dose along with another medication from a different class in full therapeutic dose for the same symptom cluster (e.g. addition of low dose haloperidol in a patient responding partially to risperidone); or the addition of a medication that would not be used alone for the same symptom cluster (e.g. augmentation of antidepressants with lithium or thyroid hormone).

Total Polypharmacy is the total count of medications used in a patient, or total drug load.For more plz read at following link

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653237/

Yes, it is observed the practice of polypharmacy in mental disorders; the meditation, transmeditation and yoga postures proved more effective along with medicine and helps in long term to reduce or withdrawal  of .medication 

Victims of polypharmacy.

Common drugs that people have complications from include drugs for anxiety and depression, sleeping pills, antipsychotics, blood-pressure tablets, proton-pump inhibitors for acid reflux.

http://www.abc.net.au/catalyst/stories/4339690.htm

30 Million Americans Are Victims to Polypharmacy  

Here’s something mind boggling to consider. In the past 10 years, research has shown that the percentage of people over 60 who take five or more medications has jumped from 22 percent to 37 percent. More than 30 million Americans take five or more prescription drugs regularly, often called “polypharmacy.”

Each year, about one-third of seniors experience serious adverse effects as a result of drug interactions, so it’s necessary to be cognizant of the risks and dangers. There are a number of measures a senior can take to avoid the health risks associated with polypharmacy. Observations and tips from Papatya Tankut, vice president, professional pharmacy services, CVS/Pharmacy:

• Developing a relationship with a pharmacist can help better manage medications and prevent potential and harmful drug interactions.
• Medication adherence is a growing concern as more Americans neglect to fill prescriptions and take medications as directed.
• Consult a pharmacist before adding any vitamins or supplements to avoid interactions.
• If a senior is unsure about a medication or is experiencing a side effect, tell the pharmacist or a trained health expert.

https://seniorcarecentralpa.wordpress.com/2012/06/11/30-million-americans-are-victims-to-polypharmacy/

Pharmacopsychiatry is mainstream in most psychiatric institutions. Psychotherapy, mostly the better way of intervention, is not favored. In Germany, one of the countries, in which psychotherapy is a real option for mental ill patients, only 15-25% of these get psychotherapy. The annual expenditures for psychotherapy are about 1,5 Mrd. €, those for psychopharmacological treatment about 3 Mrd. €, eg. 1:2 (see https://www.researchgate.net/publication/269572241_Versorgung_psychisch_kranker_Erwachsener_in_Deutschland_-_Bedarf_und_Inanspruchnahme_sowie_Effektivitat_und_Effizienz_von_Psychotherapie) . In other european countries the realtion lies at 1:10 or worse. On the other hand, the "Return-on-Investment" (ROI) for psychotherapy lies between 1:2 and 1:4,5, that means, that for one € investigation in psychotherapy the society will get back 2 - 4,50€. The ROI of psychopharmacological treatment I do not know, but I guess, he will be much worse.

Therefore: why do we invest not more in psychotherapy and less in psychopharmacotherapy?

Article Versorgung psychisch kranker Erwachsener in Deutschland - Be...

Thanks to all of you!

Dear Dr. Lewis Alan Opler thanks for this paper! This is very 'black box' topic, because something should be given to the patients in serious situations and therefore many antipsychotics are used. According to the study of Suzuki more than 2/3 of antipsychotic polypharmacy (AP) can be very successfully switched to monotherapy. Often AP is used too long, because of so called pharmacokinetic failure (e.g. DDIs, LADME process) or pharmacodynamic failure (actions on receptors).

Why AP is used so often?

- lack of knowledge of pharmacology (i think the main reason)

- SCH + OCD and another comorbidity 

- adverse events of first antipsychotic medication (e.g. use of aripiprazole with D1, D2 agonist activity)

- no treatment discontinuation after 6-8 weeks (e.g. patients with dementia treated with quetiapine)

- no reason (no respect of treatment guidelines, at least 1/3 of patients)

Why treatment guidelines are ignored so often (SCH guidelines)?

- eminence-based medicine is very strong

- no measure of treatment effect (prescribe instead of reconsider) with PANSS etc.

- no data in the patients' records about difference between AP and monotherapy (MP)

- no involvement of clinical pharmacists

- low clozapine consumption (e.g. fear of clozapine)

The main issue is to distinguish between polypharmacy and monotherapy (e.g. AP and MP). This is very important issue and small number of data has been seen on this topic. Consequently, eminence-based medicine is very strong. I also agree that psychotherapy is used in the small number of situations (e.g. depression, anxiety), dementia). In the nursing home where I work in Slovenia I see that polypharmacy can be avoided in several important situations with the use of pharmacology (e.g. high doses of trazodone instead of combination with SSRI in low doses; use of clozapine instead of polypharmacy; discontinuation of antihypertensive drugs in the patients treated with quetiapine ... ).

In the process of lowering the number of patients treated with polypharmacy, clinical pharmacists can add an additional success in thi process and therefore cooperation between physicians and clinical pharmacists next to the patients' beds are the most effective treatment strategy.

Regards,

Mathew

Antipsychotic polypharmacy was decreased and clozapine utilization increased -- we called this the RATIONAL PHARMACOTHERAPY QUALITY IMPROVEMENT (RPQI) initiative. It worked due to interdisciplinary collaboration; strong leadership; and backing by the Commissioner and cabinet of NYS' Office of Mental Health as described in attached article by Finnerty et al.

Article Best Practices: Long-Term Impact of Web-Based Tools, Leaders...

There are two problems.  One is that practitioners are almost doomed to throw unneeded or useless drugs at patients due to the uncertain nature of our diagnostic categories.  Because psychiatric diagnoses are not naturally occurring entities (such as smallpox, for instance) but are instead the products of consensus, there is no inevitable and knowable course to the illness.  There is, therefore, no way to know whether a drug has altered the course of the disorder.  In the absence of a known prognostic trajectory, there can be no solid research into the effects of a drug and thus no idea whether more (or less) of that drug might be helpful or harmful.  The second problem is cultural.  In the west the inner life has become an inconvenience, and there is almost always a strong preference for throwing an external solution at anything which takes an individual away from productivity, as opposed to trying to make sense of the person.  The two problems together mean that physicians will pile pill upon pill if patients do not report improvement.

I agree with Vance Sherwood.

Even in research, we have de-emphasized patient's subjective experience 

Canadian study 1973 @ Vancouver General Hosp, studied variations in uptake of psychoactive meds in women 65 and over: they found a 400% variation! I don't have the reference to this seminal study, but it contributes significantly to your question; Canadian psychiatrists, often in my 40 years experience, do not measure serum levels. Admittedly, this is difficult to do except w/ the meds where baselines have been established ( such as Lithium); this lack demonstrates my point relevant to your question, Matej: if we are to become serious about polypharmacy, e.g. to reduce its practice, we have to have biomarkers. W/o biomarkers, psychiatrists are free to guess - 'this patient is not responding', instead of, 'efficacious levels have not been reached'.     I hope you pursue this research question!    Psychologist Paul McGaffey

Yes. Since psychiatric drugs treat symptoms instead of getting at the root cause of what presents as "mental disorder" (which could be engendered by anything ranging from thyroid disease to vitamin deficiencies to gluten (or other food/ environmental) sensitivity ... let alone the side effect of myriad other medications) not to mention that every drug in the psychiatrists tool bag incites the very "symptoms" we associate with "mental disorder" (to include depression, endocrine dysregulation, agitation and even violence) ... and further complicated by the fact that doctors are the last ones to understand basic "cause and effect" so that even the American Psychiatric Association added "obesity" to the standard list of "symptoms" of bipolar disorder (when obesity is highly correlated with use of the drugs that are used to treat the disorder and significantly an association not present in earlier literature describing the disorder) that is only further complicated by the fact that most doctors see a new patient every 15 minutes...(a patient they likely have not seen in one to six months).... To my mind, prescribing a psychiatric drug for a "mental" symptom (outside of treatment offered in a hospital setting for an acute episode that is of short duration) without finding out what prompted the presentation of those symptoms is like a doctor giving a narcotic to a man with a broken leg while failing to set that broken leg. ..Sure a psychiatrist can offer a vague argument to support the chemical imbalance theory (a "theory" created by a pharmaceutical  company in the early 80s); but the question remains: what "caused" that "imbalance" in the first place?

Crystal Ann Barker - You can add menopause to your useful list. Upgrading from a rant category, what research question(s) will advance this deplorable situation? What changes might medical faculties be coerced into changing? Will change occur due to public outcry or occupy-action, or with robust research results (results we can loudly advertise)?   Good start.     Psychologist Paul McGaffey

ABSTRACT

Objective

This study evaluated demographic and clinical correlates and predictors of polypharmacy at baseline assessment in the Longitudinal Assessment of Manic Symptoms (LAMS) sample, a cohort of children age six to 12 years at their first outpatient mental health visit at university-affiliated clinics.

Methods

Use of medications in four classes (mood stabilizers, antidepressants, antipsychotics, and stimulants) was assessed, and the Service Assessment for Children and Adolescents classified lifetime and current use of various services. Analyses examined correlates of the number of medications prescribed and odds of polypharmacy, defined as use of two or more concurrent medications.

Results

In the total sample, 201 of 698 participants (29%) were prescribed two or more medications. These participants had lower Children's Global Assessment Scale scores, more comorbid disorders, and higher baseline parent-reported mood symptoms than those prescribed no or one medication. White youths were three times as likely as nonwhite youths to be receiving two or more psychotropics, even after adjustment for other demographic and clinical characteristics. Of 262 participants (38% of sample) not being treated with medications, 252 (96%) had a diagnosis of at least one psychiatric disorder (74% had two or more).

Conclusions

Findings suggest that patients with greater severity and comorbidity were more likely to receive two or more medications. However, 38% of these children with serious disorders were not receiving psychotropic medication at the time of this assessment. Results counter findings suggesting overtreatment with medications of children with psychiatric disorders in the community.

Article Prescription of Psychiatric Medications and Polypharmacy in ...

My big concern is given on the decision why polypharmacy is chosen? Is there appropriate trial with monotherapy in many patients? According to the data this step is very problematic in the real clinical practice and further research and education are needed. Additional question is if polypharmacy is chosen if there is appropriate scale or measurement in the patient's' documentations (charts).

I think We should analyze this two steps and then discuss on the case-by-case basis why polypharmacy is used.

Regards,

Matej

Dear Dr. Stuhec,

Unfortunately, the risk of polypharmacy is big in my country and many others in which I work and live!

I say this only from his more decades of experience and I would like to send me a few more objective reference to this matter objectively researched, and you are much more you do and you have a better experience of this interesting topic! (I read this I have been very useful for me )

Why?

It is crucial that the objective impossibility of cooperation with these patients, depending on the degree progredijencije basic disease!

The reaction in these patients on the determination of drugs can be very subjektina And it is easy to recognize, as in patients who have the disease!

It should try to objectify state-controlled determination of the drug in the blood and try to keep him in strict Referential values according to the pharmacokinetics and pharmacodynamics of the drug! HPLC methods or other ...!

Even if there is no real team of physicians, pharmacologists and clinical kinickih farmacista (usually no more of that, cast exceptions), then the only risk progressively increases!

regards

Jasenko

Yes, the patient with mental disorders are over treated with drugs, they require more counselling  rather than drugs. Yoga and meditation are most effective alone or as an add on therapy.

For 5 years I specialized my practise treating medication-resistant depressed patients, using physical exercise to lead patients, over several months, to some kind of Mindfulness. This was extraordinarily successful, but was NOT supported by psychiatrists on the team; quite frustrating.

@Matej Stuhec, Yes. I agree with you and glad you mentioned it. For decades, I saw the tragedies of mild emotional disorder became bipolar, suicide, severe mental diseases, lost sensation and sleep the whole day long. Their life was totally destroyed!

Dear Frieda,

I agree with you. In my point of view a connection between diagnosis and treatment is questionable in some cases as you mentioned before. Another story is appropriate treatment with psychopharmaceuticals, which should be established according to the newest evidence-based psychopharmacology (EBM). Polypharmacy is not well suported by EBM, especially antipsychotic polypharmacy is under question (APP). We have many negative naturalistic trials (Katona et al.) and also few positive. This discussion has been already discussed at another question. Third story is evidence about improvements in the patients data (e.g. chart). However, different scales (e.g. Hamilton, PANNS, Beck etc ...) are widely used in different academical settings, they are not used very often in clinical practice. If I sum up, undergiagnosis is often seen in some disorders (e.g. ADHD in many countries including Eastern European countries) and overtreatment could be seen also (e.g. depot-ANT with clozapine, APP etc ... ). The best approach to avoid serious polypharmacy is a collaboration among different healthcare professionals and especially with well-teached clinical pharmacist.

Regards,

Matej

Polypharmacy is the rule in clinical Psychiatry, rather then the exception. This is with special emphasis to BD cases, which are often comorbid with multiple anxiety and non-axienty disorders. While the practice of polypharmacy is the matter of vivid debate and controversies, even diagnoses which should not be treated (primarly?) with drugs according to standard guidelines are actually often prescribed with, including BPD (http://www.europeanneuropsychopharmacology.com/article/S0924-977X(15)00099-1/abstract). Interestingly, this later issue should parallel the diagnostic controversies surrounding BD/BPD comorbidity interface... Standard guidelines refer to ideal cases, not to real world patients, so the systematic exclusion of most severe cases in the RCTs (and then meta-analysis) used to synthesize the evidence, may be misleading as they systematically exclude cases with prominent psychotic features or current suicidal behavior at the time of enrollment, as well as the most severe cases (Berkson's bias) which often present with multiple comorbidities and history of treatment-refractoriness. Thus, the practice of polypharmacy is not necessarily an issue, given that it is performed owing to basic pharmacokinetics and pharmacodynamics considerations beyond treatment adhrence and cost-effective interventions. Finally, there is also an other trend associated with polypharmacy which seems quite specific of Psychiatry vs. other fields of Medicine: "adding medications to counterbalance the side effects of the first drug(s)". This later scenario is obviously misleading and inappropriate in most of the cases...

Article Prevalence and clinical features associated with bipolar dis...

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Michele thanks for these papers! I agree with you, especially in patients bith BD. This is another story. My question was general question including all mental disorders. However, polypharmacy seems to be negative in many mental disorders this is a "gold-standard", especially BD as you have discussed already before.

On the one side we have disorders, where polypharmacy is not supported by EBM (e.g. ADHD except guanfacine with combinations) and another side we have support by EBM (e.g. BD, OCD+psychosis, adverse events of antipsychotics e.g. adding aripiprazole). Interesting in patients with MDD an increased efficacy of antidepressant polypharmacy has been shown in a study published by Nelson JC et al. in Biol Psychiatry in 2004, compare to monotherapy.

If I sum up, we have very positive evidence for BD and MDD and less positive for SCH. In some disorders (e.g. BD) polypharmacy is a rule and in another disorders exception (e.g. first episode of psychosis).

Regards,

Matej

In Psychological disorders, in general the lesion or affected part of brain is very difficult to locate or identify hence the precise medicine prescription is bit difficult, so poly drug approach is adopted. Any emotional suppression with drugs uses for a longer is dangerous in long term. Many emotional uncontrolled out breaks in course of time may occur resulting in to   traumatic situation. In view of this minimum medicine with maximum counselling, meditation, yoga practices, dietetic regimen, life style change and emotional support from near and dear works effectively.

As I am psychopharmacologist I should say:

psychopharmacology + psychotherapy = the best approach

only psychopharmacology or only psychotherapy = only partial approach

We should complement each other by different specialities. This is the strongest evidence-based approach. However, this is a rule in real clinical practice we see many patients where psychopharmacological approach is more successful (e.g. SCH, adults with ADHD).

In real clinical situations we should choose among the best possible strategies. Psychopharmacological approach is better where we have a very positive evidence for example children and adolescents with ADHD, where effect sizes are almost 1 (LDX even bigger). Another side is MDD and children and adolescents, where we have small effect sizes and then psychotherapy could be a better approach (e.g. in the last meta-analysis published by Cipriani in 2016 in Lancet effect sizes were very small, except fluoxetine).

Regards,

Matej

Very interesting and interesting feature discussion of which can learn a great deal to find out!

Also excellent links and references colleagues who are obviously very knowledgeable in this field of science!

Congratulations dr.Matej the excellent questions posed and also to the excellent moderation!

With great pleasure I will continue to follow this debate and of course, if necessary, take part in it!

Greetings

Jasenko

Polypharmacy, a word with multiple definitions, both qualitative and other quantitative, is increasingly a topic of greater clinical importance, and which is being investigated throughout the world. Especially the need to deprescribe medications in geriatric patients. To encourage discussion, and contribute to the question, I wish to share the following manuscript.

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