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Polypharmacy: how bad are we really?

  • Peter Lepping and Giles C. Harborne
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Abstract
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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1 Taylor, D. Antipsychotic polypharmacy – confusion reigns. Psychiatrist 2010; 34: 41–3.
2 Langan, J, Shajahan, P. Antipsychotic polypharmacy: review of mechanisms, mortality and management. Psychiatrist 2010; 34: 5862.
3 Fleischhacker, WW, Heikkinen, T, Olie, JP, Landsberg, W, Dewaele, P, McQuade, RD, et al. Weight change on aripiprazole-clozapine combination in schizophrenic patients with weight gain and suboptimal response on clozapine: 16 week double-blind study. Eur Psychiatry 2008; 2: s1145.
4 Tungaraza, TE, Gupta, S, Jones, J, Poole, R, Slegg, G. Polypharmacy and high-dose antipsychotic regimes in the community. Psychiatrist 2010; 34: 44–6.
5 Achim, AM, Maziade, M, Raymond, E, Olivier, D, Mérette, C, Roy, MA. How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association. Schizophr Bull 2009 Dec 3 [epub ahead of print], doi: 10.1093/schbul/sbp148
6 Dernovsek, MZ, Sprah, L. Comorbid anxiety in patients with psychosis. Psychiatr Danub 2009; 21 (suppl 1): 4350.
7 Sharma, VK, Lepping, P, Cummins, AG, Copeland, JR, Parhee, R, Mottram, P. The Global Mental Health Assessment Tool – Primary Care Version (GMHAT/PC). Development, reliability and validity. World Psychiatry 2004; 3: 115–9.
8 Mortimer, AM. Update on the management of symptoms in schizophrenia: focus on amisulpride. Neuropsychiatr Dis Treat 2009; 5: 267–77.
9 Leucht, S, Corves, C, Arbter, D, Engel, RR, Li, C, Davis, JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet 2009; 373: 3141.
10 Karunakaran, K, Tungaraza, TE, Harborne, GC. Is clozapine-aripiprazole combination a useful regime in the management of treatment-resistant schizophrenia? J Psychopharmacol 2007; 21: 453–6.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
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Polypharmacy: how bad are we really?

  • Peter Lepping and Giles C. Harborne
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eLetters

Polypharmacy: saint or sinner

Deji Odelola, Consultant Psychiatrist
17 May 2010



Lepping and Harbone (2010) query the notion that polypharmacy rates are increasing. The general consensus however, is that polypharmacy rates are indeed rising and previous studies clearly report this trend (1,2). It is also not certain that the study by Tungaraza et al (2010) is the first community study of polypharmacy in the United Kingdom, as our study (Ranceva et al 2010) probably predates it.

The findings from our study were strikingly similar to those of Tungaraza et al (2010) in showing almost identical out-patient polypharmacy rates of 17.4%, and a prevalence of high dose prescribing and sedative use in association with polypharmacy. These results were obtained despite the fact that our study population in Rochdale would not be considered severely ill. Both studies showed a tendency for atypical antipsychotics to be commonly involved in combination or high dose prescribing- perhaps asking questions as do Lepping and Harbone about the efficacy in the real-life clinical situation of atypicals.

That polypharmacy continues despite repeated guidance against it, may indicate that this is perhaps one area in which clinical practice and observation is ahead of research evidence which is yet to catch up. Lepping and Harbone make the point that in the case of polypharmacy, the evidence provides no support one way or the other. There however appears now to be a shift away from a blanket condemnation of antipsychotic polypharmacy, to a search for evidence based recommendations which would support a role for polypharmacy in everyday clinical practice. Langan and Shajahan (2010) provide a number of excellent recommendations based on a thorough review of the existing literature. Not all of these recommendations may however be applicable in everyday clinical practice.

Several studies including ours (5) have shown poor adherence to standards requiring documentation of clinical practice, or the recording of investigation reports such as ECGs. Recent audits have advocated review by pharmacists which may be feasible for inpatients but less so in outpatient populations. It is similarly problematic to conceive of a mechanism to ensure that cross-tapering of medication is completed and not abandoned half-way through. The idea of switching back from polypharmacy to monotherapy in identified cases sounds attractive and has been shown successful in a proportion of patients(3) but clinicians may still remain wary of the problem of inducing psychotic relapses in otherwise stable patients with all the associated consequences- including of a fatal outcome.

What is clear perhaps is that the antipsychotic polypharmacy issue is unlikely to go away. The current attempts to “manage” polypharmacy through audit, guidelines, and recommendations have not led to change, and polypharmacy remains in many ways “treatment resistant”. It may be time perhaps to be open- minded about psychiatry’s “dirty little secret” and allow the “co-prescribing” of new measures focussed on achieving a better understanding of the polypharmacy phenomenon.



Centorrino F, Eakin M, Bahk WM, Kelleher JP, Goren J, Salvatore P, et al. In-patient antipsychotic drug use in 1998, 1993 and 1989. American Journal of Psychiatry 2002; 159: 1932-1935.

Gilmer TP, Dolder CR, Folsom DP, Mastin W, Jeste DV. Antipsychotic polypharmacy trends among Medi- cal beneficiaries with schizophrenia in San Diego County, 1999-2004. Psychiatric Services 2007; 58 (7): 1007-1010.

Langan J, Shajahan P. Antipsychotic polypharmacy: review of mechanisms, mortality and management. Psychiatrist 2010; 34: 58-62.

Lepping P, and Harbone GC. Polypharmacy: how bad are we really? Psychiatrist 2010; 34 (5): 208-209.

Ranceva N, Ashraf W, Odelola D. Antipsychotic Polypharmacy in Outpatients at Birch Hill Hospital: Incidence and adherence to guidelines. J Clin Pharmacol 2010; 7 Jan, epub.

Tungaraza TE, Gupta S, Jones J, Poole R, Slegg G. Polypharmacy and high dose antipsychotic regimes in the community. Psychiatrist 2010; 34: 44-46.
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