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May 07, 2007
Polypharmacy in Psychiatric Medicine
What exactly is "polypharmacy"? Is it beneficial? Is it harmful? Why would doctors use it? Why not? These are questions frequently raised among patients and families of people with schizophrenia-spectrum disorders struggling to understand the cornucopia of medications often prescribed for complex psychiatric disorders.
There is a frank discussion about polypharmacy by Doctors Steven J. Kingsbury and Megan Leahy Lotito on Psychiatric Times that is educational and enlightening.
The writers define polypharmacy as "the use of 2 or more medications of the same chemical class or with the same or similar pharmacological actions to treat the same condition or separate conditions." In other words - polypharmacy is when multiple medications are used to alleviate the same disorder or illness symptom, or two varieties of the same type of medication is used to treat two different disorders.
Examples of what constitutes polypharmacy - and what doesn't - can be much more helpful in understanding what this concept actually is.
An example of two medications of the same "chemical class" or "pharmacological action" would be two types of antidepressants or two types of antipsychotics. Using two antipsychotics would be considered "polypharmacy" even if they are ostensibly being used for two different symptoms, such as one being used for psychosis and the other being used to aid sleep.
A medication given to combat the side-effects of another medication is not considered "polypharmacy".
The authors also suggest that the same two medications in one case would "polypharmacy" and in another case would not be. An example of that being a person on an antidepressant and on thyroid medication at the same time. It is not polypharmacy if the person needs the thyroid medication for hypothyroidism, but it is considered polypharmacy if the thyroid medication is simply being used to augment the effects of the antidepressant.
OK - so now that we know what polypharmacy is, we have the questions about why it might be used, and what might be the benefits and the dangers involved.
The authors discuss that there are times when polypharmacy might be beneficial. Polypharmacy is simply sometimes used to obtain more effective results when a single agent has not been found to be effective enough to give the desired results.
There are some well-researched uses of medication combinations, such as using lithium or valproate with the second-generation antipsychotics for treatment of manic episodes in bipolar disorder.
However, there still is little hard research data available about the efficacy of most combinations of medications, simply because there are so many possible combinations. Therefore, doctors often use "rational polypharmacy" based on the known research results and expert opinions pertaining to similar combinations.
But, the authors warn, there are times when polypharmacy is not warranted, and there are dangers to polypharmacy, especially when the medications may compete using the same metabolic pathways. For this reason, medical practitioners need to be familiar with existing research, the mechanisms of action of medications, and metabolic pathways in order to use rational polypharmacy.
They also give the reminder that people react differently to the same combinations of medications, and they must be monitored for their own unique reactions.
The authors conclude:
If future trends in psychiatric disease management follow along their current route, polypharmacy will continue to be necessary in order to obtain optimal therapeutic goals. With this in mind, it becomes imperative for providers to remain judicious when using polypharmacy strategies in the treatment of psychiatric disorders.
Posted by Jeanie Wolfson at May 7, 2007 07:30 AM
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