Polypharmacy in Psychiatry
Only recently “polypharmacy” was a pejorative term implying nonscientific and, perhaps, even sloppy care. This was all the more so as diagnoses became more refined, information regarding the neurobiology of psychiatric disorders increased, and the mechanisms of action of psychotropic medications became progressively more clear--developments that held out the promise of a neurophysiology of psychiatric disorders with drugs designed appropriately to match.
In this book’s opening chapter, Dr Nassir Ghaemi carefully discusses the history of polypharmacy, including the fluctuations in attitude toward this practice over time that directly reflect the level of understanding of medical illnesses. He feels that, today, polypharmacy persists in part because psychiatric disorders continue to be difficult to understand, despite vast progress in the neuroscience of psychiatric disorders over the past decade and a half.
There are several other factors, which he details. For example, it is an important fact that drugs are marketed for specific diagnoses on the basis of research that employs drug--disease paradigms--even though in the real world patients present with clinically complex symptoms rather than with discrete syndromes matching the actions of a particular drug or class of drugs.
The book is part of the Medical Psychiatry series edited by William A Frosch. It has 14 chapters by 14 authors and coauthors. The opening chapter, by Ghaemi, defines the conceptual and historical background of polypharmacy in psychiatry from the time of Oliver Wendell Holmes. It discusses William Osler and the early struggles between psychotherapy, psychoanalysis, and pharmacologic treatment (with barbiturates and sedatives) and includes the introduction of the phenothiazenes and the tricyclics. Ghaemi also mentions the efforts of several people familiar to the reader, including Gerald Klerman of Yale and Harvard and Gerald Sarwer-Foner of the University of Ottawa, Ottawa, Canada. Sarwer-Foner is mentioned as someone who began in the 1960s to specialize in the relation between psychopharmacology and psychotherapy.
Ghaemi also presents the US Food and Drug Administration as a powerful influence in the evolution of polypharmacy and attitudes toward its practice. The way drugs have been approved by the US Food and Drug Administration and marketed by drug companies, and also the US cultural and historical appetite for pharmacologic treatment, are seen as significant contributors. Other important factors, such as research findings on biogenic amines in depression and schizophrenia, elucidate the mechanisms of action of drugs and the development of the DSM. Ghaemi concludes by emphasizing that polypharmacy is part of psychiatry today.
Ghaemi also devotes much attention to defining polypharmacy, distinguishing between rational and irrational polypharmacy. Some disorders (for example, bipolar disorder [BD]) historically require 2 or more drugs for adequate treatment of the disorder and its associated symptoms. In such cases, polypharmacy is not only rational but may be standard treatment.
Eight chapters discuss polypharmacy for different disorders according to the following diagnoses or clinical groupings: BD, unipolar depression, schizophrenia, anxiety disorders, and posttraumatic stress disorder. Polypharmacy for medically ill psychiatric patients, the elderly, and children and adolescents is also discussed. The question of defining polypharmacy is taken up in each chapter. In the chapter on BDs, for example, it is argued that standard treatment requires at least 2 drugs. Therefore, polypharmacy would be 3 or more drugs in the case of this disorder. Various aspects of the diagnosis and treatment of BD are discussed as they relate to polypharmacy. The chapter’s author emphasizes that, in treating BD, the focus should be on the long-term perspective, which requires more than one drug. Polypharmacy in mania and bipolar depression are discussed separately. The chapter also discusses the polypharmacy and prophylaxis of BD, the side effects burden of polypharmacy, and suggested guidelines for treatment.
Each chapter reviews both the controlled and open studies of polypharmacy in the particular disorder or clinical group addressed; what is surprising is how little systematic study of this widespread practice exists. Each chapter is equally comprehensive, although not similarly organized.
The chapters on the medically ill and the elderly demonstrate how unavoidable polypharmacy is in these populations because of both medical and psychiatric comorbidities; therefore, adequate knowledge of psychotropic--nonpsychotropic medication interactions is required. The pharmacokinetic and pharmacodynamic changes in the elderly both contribute to polypharmacy through a phenomenon called the “prescribing cascade,” in which an adverse drug reaction is interpreted as a new medical problem. The chapter on children and adolescents mainly emphasizes the large contribution of comorbidity to polypharmacy. This chapter is less than thorough; for example, it makes no mention of oppositional defiant disorder, a common comorbidity in many child and adolescent diagnoses.
Of the remaining 5 chapters, 2 are particularly interesting, both for the topics themselves and for the fact that they were given so much space. “Psychosocial Aspects of Polypharmacy: the Social work Perspective” discusses the increased role of social workers in the care and rehabilitation of patients since deinstitutionalization and community reintegration. In regard to pharmacotherapy and polypharmacy, the author sees social workers acting as physicians’ assistants, consultants, counsellors, educators, monitors, and advocates in collaboration with the physician.
“Polypharmacy of Alternative and Herbal Medication” acknowledges the significant use among psychiatric patients of natural medications, as well as vitamins and other supplements, for both psychiatric and nonpsychiatric symptoms. The chapter summarizes what is known about the actions and mechanisms of some of these drugs and, in the absence of adequate information for the more commonly available naturopathic drugs, offers suggestions. The last 3 chapters on the psychology of polypharmacy, on cultural aspects of polypharmacy, and on the “pills and potions,” make important points; however, they could probably be condensed into a single chapter, particularly since some of the points covered are partly treated in the opening chapter.
I found this book a pleasure to read, not only because of the topic and the content but also because it is comprehensive, well written, and well laid out. The subject is explored both extensively and intensively, and the many personal and first-hand references render the authors both authoritative and close. True to its stated purpose, the book gives readers a broad view of polypsychopharmacology historically and provides direction on where and how to engage in polypsychopharmacotherapy. The historical and conceptual background is, I think, a significant contribution that puts this current practice in an appropriate perspective. The book’s other, and most significant, contribution is its examination and competent discussion of the extant literature on the subject.
Although the price is steep, I strongly recommend this book for any clinician or teacher seriously interested in the subject, both for ongoing use and as a valuable reference.
--Llewellyn W Joseph MD, FRCPC, Canadian Journal of Psychiatry, August 2005