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    1 Comment for this article
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    Adjunctive Psychotherapy: An evidence based alternative to antipsychotic polypharmacy
    Brian B Sheitman, M.D. | UNC Chapel Hill
    The recent publication by Mojtabai and Olfson (1) once again highlights the widespread and growing use of psychotropic polypharmacy without a strong evidence base of support. The authors point out how there remains great uncertainty about whether there really is any clinical efficacy to these combinations, and whether the increased risk for adverse effects and unknown drug-drug interactions is justified. This publication adds to a growing literature indicating that there needs to be some curb on polypharmacy prescribing. However, what is less clear is what are the alternatives to polypharmacy. As practicing psychiatrists who work with the severely mentally ill, we have many patients who experience distress due to refractory symptoms. If patients have been generally adherent with their medication regimen, and clozapine has been tried for refractory positive symptoms, as Mottabai and Olfson (1) point out there is minimal to no guidance in terms of rational polypharmacy. Most patients in these situations typically want to try something, and most patients and their families are dissatisfied with a response that “we have no other evidence based treatments for you”.
    A piece that may be missing from this equation is the use of adjunctive psychotherapy. While there is no evidence to support a second antipsychotic for refractory psychosis, there is fairly good evidence to support cognitive-behavioral therapy (2) as an adjunctive treatment for refractory psychosis. As best as we can tell, adjunctive psychotherapy is not widely used. It seems to be time for the field of psychiatry to re-adjust our balance between the use of medication and therapy. In our opinion, treatment for psychotic disorders, and the research that supports it, has focused far too much on medications only. Based on the available data, there are clear limits to what we can expect from medications alone (3).
    The author reports no conflicts of interest.
    (1) Mojtabai R, Olfson MO. National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry 2010/vol 67 (1): 26-36.
    (2) Dixon LB, Dickerson F, Bellack AS, Bennett M, Dickinson D, Goldberg W, Lehman A, Tenhula WN, Calmes C, Pasillas RM, Peer J, Kreyenbuhl J. The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin 2009 vol 36(1): 48-70.
    (3) Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK, Clinical Antipsychotic trials of Intervention effectiveness. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005 (12): 1209-23.
    CONFLICT OF INTEREST: None Reported
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    Original Article
    January 2010

    National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry

    Author Affiliations

    Author Affiliations: Department of Mental Health, Bloomberg School of Public Health, and Department of Psychiatry, Johns Hopkins University, Baltimore, Maryland (Dr Mojtabai); and Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York (Dr Olfson).

    Arch Gen Psychiatry. 2010;67(1):26-36. doi:10.1001/archgenpsychiatry.2009.175
    Abstract

    Context  Psychotropic medication polypharmacy is common in psychiatric outpatient settings and, in some patient groups, may have increased in recent years.

    Objective  To examine patterns and recent trends in psychotropic polypharmacy among visits to office-based psychiatrists.

    Design  Annual data from the 1996-2006 cross-sectional National Ambulatory Medical Care Surveys were analyzed to examine patterns and trends in psychotropic polypharmacy within nationally representative samples of 13 079 visits to office-based psychiatrists.

    Setting  Office-based psychiatry practices in the United States.

    Participants  Outpatients with mental disorder diagnoses visiting office-based psychiatrists.

    Main Outcome Measure  Number of medications prescribed in each visit and specific medication combinations.

    Results  There was an increase in the number of psychotropic medications prescribed across years; visits with 2 or more medications increased from 42.6% in 1996-1997 to 59.8% in 2005-2006; visits with 3 or more medications increased from 16.9% to 33.2% (both P < .001). The median number of medications prescribed in each visit increased from 1 in 1996-1997 to 2 in 2005-2006 (mean increase: 40.1%). The increasing trend of psychotropic polypharmacy was mostly similar across visits by different patient groups and persisted after controlling for background characteristics. Prescription for 2 or more antidepressants, antipsychotics, sedative-hypnotics, and antidepressant-antipsychotic combinations, but not other combinations, significantly increased across survey years. There was no increase in prescription of mood stabilizer combinations. In multivariate analyses, the odds of receiving 2 or more antidepressants were significantly associated with a diagnosis of major depression (odds ratio [OR], 3.44; 99% confidence interval [CI], 2.58-4.58); 2 or more antipsychotics, with schizophrenia (OR, 6.75; 99% CI, 3.52-12.92); 2 or more mood stabilizers, with bipolar disorder (OR, 15.46; 99% CI, 6.77-35.31); and 2 or more sedative-hypnotics, with anxiety disorders (OR, 2.13; 99% CI, 1.41-3.22).

    Conclusions  There has been a recent significant increase in polypharmacy involving antidepressant and antipsychotic medications. While some of these combinations are supported by clinical trials, many are of unproven efficacy. These trends put patients at increased risk of drug-drug interactions with uncertain gains for quality of care and clinical outcomes.

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