The jury is still out!

Lepping & Harborne ¹ highlight the unfortunate conflation of ‘psychotropic polypharmacy’ and ‘antipsychotic polypharmacy’, which is seen in the study by Tungaraza et al ² and which may confuse the reader. Their response falls foul of this issue when they refer to the statement that ‘only a third of [patients] were on one psychotropic medication’, and draw an implication of a shortfall in compliance with the National Institute for Health and Clinical Excellence schizophrenia guideline. ³ The guideline advocates sequential use of antipsychotic monotherapy, but does not discuss polypharmacy involving other psychotropic medication. Lepping & Harborne rightly point out that both Taylor ⁴ and Tungaraza et al have made assessments about the temporal change of incidence of antipsychotic polypharmacy without references, but later they mention studies of clozapine-amisulpride and clozapine-quetiapine combinations which are unreferenced.

An internal in-patient survey of antipsychotic polypharmacy in our own trust demonstrated an incidence broadly similar to that found in the literature at the time, but that antipsychotic polypharmacy regimes were not centred around attempts to optimise clozapine treatment. Rather, a variety of regimes involving diverse antipsychotics was seen. It is perhaps speculative to presume that in the Wrexham cohort ² most people on two or more antipsychotics were taking clozapine. In the forensic setting, complexity and diagnostic plurality is the norm, so antipsychotic polypharmacy is perhaps unavoidable at times. It is our concern that procedural aspects, such as preconditions for assured concordance before transfer to step-down services, may sometimes colour the prescribing decisions and drive the co-administration of depot antipsychotics with oral atypicals. We could not find reference to non-medical prescribers in Taylor's article. Indeed, we feel that Tungaraza et al suggest that the emergence of new groups of prescribers points out the urgency of resolving issues around antipsychotic polypharmacy, broadly anticipating the concerns of Lepping & Harborne. Finally, we respectfully suggest that the word polypharmacy be reconsidered, since pharmacy is seldom the originator of the plan!