Polypharmacy: saint or sinner?

Lepping & Harbone ¹ query the notion that polypharmacy rates are increasing. The general consensus, however, is that polypharmacy rates are indeed rising and previous studies clearly report this trend. ^2,3 It is also not certain that the study by Tungaraza et al ⁴ is the first community study of polypharmacy in the UK, as our study ⁵ probably predates it.

The findings from our study were strikingly similar to those of Tungaraza et al in showing almost identical out-patient polypharmacy rates of 17.4% and 17.5% respectively, and a prevalence of high-dose prescribing and sedative use in association with polypharmacy. These results were obtained despite the fact that our study population would not be considered severely ill. Both studies showed a tendency for atypical antipsychotics to be commonly involved in combination or high-dose prescribing - perhaps asking, as do Lepping & Harbone, about the efficacy of atypicals in the real-life clinical situation.

That polypharmacy continues despite repeated guidance against it may indicate that this is perhaps one area in which clinical practice and observation is ahead of research evidence, which is yet to catch up. Lepping & Harbone make the point that in the case of polypharmacy the evidence provides no support one way or the other. There appears now, however, to be a shift away from a blanket condemnation of antipsychotic polypharmacy to a search for evidence-based recommendations, which would support a role for polypharmacy in everyday clinical practice. Langan & Shajahan ⁶ provide a number of excellent recommendations based on a thorough review of the existing literature. Not all of these recommendations may, however, be applicable in everyday clinical practice.

Several studies, including ours, ⁵ have shown poor adherence to standards requiring documentation of clinical practice, or the recording of investigation reports such as electrocardiograms. Recent audits have advocated review by pharmacists, which may be feasible for in-patients but less so in out-patient populations. It is similarly problematic to conceive of a mechanism to ensure that cross-tapering of medication is completed and not abandoned half-way through. The idea of switching back from polypharmacy to monotherapy in identified cases sounds attractive and has been shown successful in a proportion of patients, ⁶ but clinicians may still remain wary of the problem of inducing psychotic relapses in otherwise stable patients, with all the associated consequences, including a fatal outcome.

What is clear perhaps is that the antipsychotic polypharmacy issue is unlikely to go away. The current attempts to ‘manage’ polypharmacy through audit, guidelines and recommendations have not led to change, and polypharmacy remains in many ways ‘treatment resistant’. It may be time to be open-minded about psychiatry's ‘dirty little secret’ and allow the ‘co-prescribing’ of new measures focused on achieving a better understanding of the polypharmacy phenomenon.