Prevalence of Antipsychotic Polypharmacy and Associated Factors among Outpatients with Schizophrenia Attending Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia

By Tesfaye, Siranesh; Debencho, Nigussie et al. | Psychiatry Journal, Annual 2016 | Go to article overview

Prevalence of Antipsychotic Polypharmacy and Associated Factors among Outpatients with Schizophrenia Attending Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia


Tesfaye, Siranesh, Debencho, Nigussie, Kisi, Teresa, Tareke, Minale, Psychiatry Journal


1. Introduction

Schizophrenia is a severe mental illness with a serious impact on the lives of patients and their families. Treatment with antipsychotic drugs has been the main part of treatment and management of psychotic patients globally [1]. These patients exhibit marked interindividual variability in their response to antipsychotics and some of them have poor response to several antipsychotics or even no response at all. Therefore, common strategy in management of these difficult to treat patients is combination of antipsychotic agents [2].

Antipsychotic polypharmacy (APP) is the use of two or more antipsychotic drugs at a time for a given patient. Study in USA reported a prevalence of 27.5% antipsychotic combination which is similar to that in South Africa (28.6%) and the study done in six East Asian countries and territories (China, Hong Kong, Japan, Korea, Singapore, and Taiwan) revealed that the prevalence of antipsychotic polypharmacy was 45.7% [3, 4], while a Nigerian study reported a 92% prevalence polypharmacy [5]. These discrepancies in prevalence of antipsychotic combination across studies may be accounted for by differences in the definition of antipsychotic combination and also availability and type of medical insurance for schizophrenia patients as well as clinical experience and knowledge of psychopharmacology by medical practitioners [6].

Despite recommendations by guidelines to avoid combinations of antipsychotics unless after multiple trials of antipsychotic monotherapy, it is quite a common practice to use combinations [7]. In addition to this, patients who need antipsychotic doses more than the maximum recommended are often prescribed two antipsychotics [3].

When more than one antipsychotic drug is prescribed at a time, it is difficult to identify the antipsychotic agent which reduced the psychotic symptoms and the other which is responsible for the adverse effects. The frequently reported reason for antipsychotic polypharmacy is that if one agent does not achieve the desired therapeutic outcome for controlling positive and/or negative symptoms, another medication within the same class can be added to address the uncontrolled symptoms. But this practice on the contrary leads to unnecessary expenses and exposes the patient to severe drug adverse effects.

Therefore, long term use of antipsychotic polypharmacy is recommended only as a last resort after having exhausted monotherapy alternatives [2, 8]. In this study, frequency of antipsychotic combinations in Amanuel Mental Specialized Hospital was examined. Furthermore, factors associated with antipsychotic combination were investigated.

2. Methods

A cross-sectional study design was conducted at Amanuel Mental Specialized Hospital (AMSH) in Addis Ababa from April to May, 2014. AMSH is one of the oldest hospitals established in 1937 and located in western part of Addis Ababa, the capital city of Ethiopia. The hospital is playing its pivotal role as a training institute for psychiatric professionals so as to expand psychiatry service to the primary health care system of the country. There were about 51,204 schizophrenia patients who had regular follow-up in a year period at outpatient department; and on average 4,267 schizophrenia patients had monthly follow-up. The study population was schizophrenia outpatients who were on regular treatment and who had follow-up during the study period at AMSH. Patients aged 18 years and above and who had one or more previous visits were involved in the study. Patients with medical or neurological illnesses, who had no insight, and who were unable to communicate were excluded from the study.

2.1. Sample Size and Sampling Procedures. The sample size was calculated using the formula [n = ((z[alpha]/2)2p(1 - p))/d2] for estimating a single population proportion at 95% confidence interval (CI) (Z[alpha]/2 = 1.96) and 5% margin of error. Due to absence of data in the country, proportion of population who took polypharmacy antipsychotic among schizophrenia patients was assumed to be 50%, and by adding 10% contingency for nonresponse rate, a total of 423 study populations were involved. …

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