Magazine article Clinical Psychiatry News

Antipsychotics: Prescribe One at a Time

Magazine article Clinical Psychiatry News

Antipsychotics: Prescribe One at a Time

Article excerpt

Too many clinicians prescribe more than one antipsychotic at a time to patients with schizophrenia, a generally unhelpful and expensive practice.

Only in rare, exceptional cases should simultaneous antipsychotics be tried when treating schizophrenia, several experts suggest.

"There's no question that it's very common" to combine antipsychotics for schizophrenia, Dr. Donald C. Goff said. "Probably 30%-40% of patients with schizophrenia are treated with more than one antipsychotic, and I would say in the vast majority of cases, it's unnecessary and probably not a good idea."

Clinicians commonly fail to complete the tapering off of one antipsychotic when switching to another, leaving the patient on two drugs, he said. Or, clinicians desperately trying to help a patient debilitated by schizophrenia add a second or third drug and allow to patient to continue even when there's no evidence of benefit. "Patients can end up collecting two, three, or four antipsychotics, even though it's not clear that the combination helped," said Dr. Goff, director of the schizophrenia program at Massachusetts General Hospital, Boston.

One good, placebo-controlled study reported that adding risperidone improved response rates in some patients who had schizophrenia and who had little or no response to clozapine. But other study results are mixed, he added. "That's not enough to recommend it as a well-established treatment approach, because it's not. On the other hand, for the individual desperate patient, I think it justifies a time-limited trial," he said.

Misunderstandings about the timing of therapy lead some clinicians into thinking that antipsychotic polypharmacy is helpful for schizophrenia, said Dr. Herbert Y. Meltzer, director of the schizophrenia research program at Centerstone Mental Health Center and professor of psychiatry at Vanderbilt University, both in Nashville, Tenn.

"Often, when people think [polypharmacology] is helpful, they have just failed to adequately optimize the dose of the drug they're using, or they're on the wrong drug to begin with," he said. "I've never run into a situation where I've ever found it to be helpful," Dr. Meltzer added, though he's open to the idea that in very rare cases combining antipsychotics may be legitimate.

Clinicians resort to antipsychotic polypharmacy because they want to help patients with resistant disease but also because they are under pressure to discharge quickly patients who are hospitalized. Instead of waiting for one antipsychotic to take effect, clinicians add another. If the patient improves, they attribute that improvement to the second drug instead of the "time effect" of the first drug, he said. "That happens in the outpatient service as well."

Combining antipsychotics may result in side effects or reduced efficacy through competing mechanisms of action. "What they're doing is useless [or] harmful and leads to detrimental effects in many instances," Dr. Meltzer said.

He and associates conducted a randomized, double-blind study in which risperidone or placebo was added to the treatment of patients with schizophrenia that was refractory to clozapine. The placebo group had better outcomes in the positive and negative symptoms of schizophrenia, which "meant that the risperidone was actually harming the placebo effect," he said (N. …

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