A VIEW OF POLYPHARMACY

May 1, 2006

The author continues his analysis, begun 25 years ago, of the use of polypharmacy versus monotherapy with an antipsychotic agent. Although antipsychotic polypharmacy has been condemned over the years, the practice nevertheless continues and has shown marked increase with the introduction of atypical antipsychotic agents.

Gardos G. Antipsychotic polypharmacy or monotherapy? Neuropsychopharmacol Hung. 2005;7:72-77.

Summary

The author continues his analysis, begun 25 years ago, of the use of polypharmacy versus monotherapy with an antipsychotic agent. Although antipsychotic polypharmacy has been condemned over the years, the practice nevertheless continues and has shown marked increase with the introduction of atypical antipsychotic agents.

Experts suggest that polypharmacy is appropriate if a patient does not respond after adequate trials of monotherapy, during the transition from one antipsychotic agent to another, and when acutely psychotic patients express significant aggression or agitation. The potential for increased side effects, drug interactions, and cost is noted.

The author concludes that the literature reviewed does not demonstrate that polypharmacy is superior to monotherapy in effectiveness.

Commentary

This article, based on a presentation at the VIIth Hungarian Congress of Neuropsychopharmacology, is more a commentary than a comprehensive review of antipsychotic polypharmacy. Several relevant articles, including those related to augmentation with 2 antipsychotics for enhanced efficacy, are not included in this review.

It is difficult, however, not to concur with the overall recommendations from this article: judicious use of antipsychotic polypharmacy, and regular reevaluation of the context and risk-benefit analysis of this strategy during treatment. The final conclusion--"[n]ew research will pave the way towards more specific and more effective pharmacotherapy and will eventually obviate the need for antipsychotic polypharmacy"--seems highly speculative. If the pattern of polypharmacy in the era of new second-generation antipsychotics is anything to go by, this conclusion is probably in error.

Peter F. Buckley, MD Professor and Chairman Department of Psychiatry Medical College of Georgia Augusta