Risks of Polypharmacy in Psychiatric Patients Diminish With Medication Therapy Management
When it comes to psychiatric medications, it’s never easy to balance optimal treatment with the potential for adverse effects. Consider an atypical antipsychotic that turns a raging adolescent into a calm, functioning teen—and comes coupled with such significant weight gain that metabolic disease knocks at the door.
A patient’s risks only increase with multiple medications, which is why the rising prevalence of psychiatric polypharmacy is cause for concern. And, of course, the danger multiplies when additional physicians prescribe medications for comorbid conditions. Pharmacists can fill in the missing component—communication between providers—and promote better outcomes through medication therapy management.
Current Issues in Psychiatric Polypharmacy
By all accounts, psychiatric polypharmacy is common and on the rise. Increasing polypharmacy is a trend both for inpatients and those being discharged. Information from the National Ambulatory Medical Care Survey shows that one-third of psychiatric outpatients take three or more psychotropic medications.1 Yet it’s impossible to tie down prevalence rates, with estimates that range from 13 to 90 percent for overall psychiatric polypharmacy.2 A review of antipsychotic polypharmacy for the treatment of schizophrenia doesn’t help narrow the data; it put the prevalence at 4 to 70 percent, depending on the setting and the population.3
Another trend fueling concern is the ever-increasing use of antipsychotic polypharmacy in youth, with an estimated 6 percent of children and 12 percent of adolescents taking multiple antipsychotics.4 A systematic review of the literature found that the most common diagnoses in children below the age of 13 were attention-deficit hyperactivity disorder and conduct disorder or oppositional defiant disorder. In adolescents taking antipsychotics, the top diagnoses were schizophrenia-spectrum disorders, anxiety disorders, and bipolar-spectrum disorders.
One of the confounding issues in the debate over polypharmacy is that it’s the best clinical decision for some patients. Polypharmacy can’t always be implemented only after monotherapy has failed—even though that’s what is recommended—because patients with severe psychopathology won’t benefit from an initial trial of a single agent, and their condition may worsen in the meantime. And for patients with schizophrenia, antipsychotic polypharmacy should always be the exception rather than the rule.
Classification and Recommendations from NASMHPD
For pharmacists, polypharmacy usually refers to three or more medications prescribed for the same patient, but in psychiatry the definition is a little different. Psychiatric polypharmacy means the use of two or more psychiatric medications in the same patient, or the use of two or more medications from the same chemical class to treat the same condition. The National Association of State Mental Health Program Directors (NASMHPD) divides psychiatric polypharmacy into these categories:5
- Same-Class Polypharmacy: The use of more than one medication from the same medication class.
- Multi-Class Polypharmacy: The use of full therapeutic doses of more than one medication from different medication classes for the same symptom cluster.
- Adjunctive Polypharmacy: The use of one medication to treat the side effects or secondary symptoms of another medication from a different medication class.
- Augmentation: The use of one medication at a lower than normal dose, along with another medication from a different class at its full therapeutic dose for the same symptom cluster. This category also includes the addition of a medication that would not be used alone for the same symptom cluster.
The report states that there isn’t enough evidence to justify same-class polypharmacy, but the other three categories represent safe and effective treatments.
The NASMHPD also recommends that physicians avoid prescribing more than one agent from the following medication classes:
- Typical antipsychotics
- Selective serotonin reuptake inhibitors
- Tricyclic antidepressants
- Monoamine oxidase inhibitors
Pharmacist Outreach for Polypharmacy
Pharmacists are well aware of the potential risks of psychiatric polypharmacy, from cumulative toxicity and the increased risk of adverse events to pharmacokinetic interactions. When you counsel patients, it’s also important to remember the impact of complex therapeutic regimens on adherence rates and drug costs. Be sure to give priority to polypharmacy patients and pay extra attention to the following groups:
- Patients with prescriptions from primary care physicians: When primary care physicians, whether pediatricians or family practitioners, prescribe psychotropic medications for children and teens, 21 percent receive two or more different classes of drugs for at least three months.6 Scrutinize these prescriptions to be sure these young patients aren’t taking an unsafe combination of medications.
- Patients recently discharged: At least 12 percent of all adults released from psychiatric hospitals are prescribed multiple drugs, according to the Journal of Psychiatric Practice in July 2016.7 A different study reported that about the same percentage of children are discharged with antipsychotic polypharmacy. These patients are at a higher risk of medication problems, so they need increased support and counseling in the outpatient setting.
- Elderly patients: Polypharmacy in elderly patients is common due to chronic health conditions. Those with dementia are also likely to be prescribed antipsychotics on top of their already complex regimen. Schedule regular medication reviews to prevent adverse effects and promote adherence.
Communication with Providers Improves Patient Outcome
Time and again, articles about psychiatric polypharmacy bring up communication—or, more accurately, they mention that communication between physicians is often lacking, which leads to the risk of prescriptions for medications that interact with psychotropics. Pharmacists can solve this problem by purposefully communicating with all prescribing physicians to discuss issues related to polypharmacy. You can even take the extra step of establishing a formal health care team. The counseling and education you provide will significantly benefit a vulnerable group of patients.
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- “National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry,” January 2010, http://www.ncbi.nlm.nih.gov/pubmed/20048220/ ↩
- “Polypharmacy in Psychiatry: A Review,” January 2013, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653237/ ↩
- “Critical Review of Antipsychotic Polypharmacy in the Treatment of Schizophrenia,” July 2014, http://ijnp.oxfordjournals.org/content/17/7/1083 ↩
- “Prevalence and Correlates of Antipsychotic Polypharmacy in Children and Adolescents Receiving Antipsychotic Treatment,” July 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010557/ ↩
- “NASMHPD Medical Directors’ Technical Report on Psychiatric Polypharmacy,” October 2001, http://www.nasmhpd.org/sites/default/files/Polypharmacy.pdf ↩
- “PAS: Psychotropic Polypharmacy Widespread in Pediatric Primary Care,” May 2015, http://www.pediatricnews.com/specialty-focus/mental-health/single-article-page/pas-psychotropic-polypharmacy-widespread-in-pediatric-primary-care/669964785971adfec6236f801ab097fb.html?trendmd-shared=0 ↩
- “Antipsychotic Medication Prescribing Practices Among Adult Patients Discharged From State Psychiatric Inpatient Hospitals,” July 2016, http://journals.lww.com/practicalpsychiatry/Fulltext/2016/07000/Antipsychotic_Medication_Prescribing_Practices.4.aspx ↩