Abstract
Current treatment standards in psychiatry are oriented towards polypharmacy, that is, patients receive combinations of several antidepressants, antipsychotics, mood stabilizers, anxiolytics, hypnotics, antihistamines, and anticholinergics, along with other somatic treatments. In tandem with the beneficial effects of psychopharmacological drug treatment, patients experience significant adverse reactions which appear to have become more frequent and more severe with the rise of ubiquitous polypharmacy. In this study, we aimed to assess today’s acute inpatient treatment of depressive and schizophrenic disorders with focus on therapeutic strategies, medications, adverse side effects, time course of recovery, and efficacy of treatments. Of particular interest was the weighing of the benefits and drawbacks of polypharmacy regimens. We recruited a total of 320 patients hospitalized at three residential mental health treatment centers with a diagnosis of either schizophrenic (ICD-10: “F2x.x”; n = 94; “F2 patients”) or depressive disorders (ICD-10: “F3x.x”; n = 226; “F3 patients”). The study protocol included (1) assessment of previous history by means of the SADS Syndrome Check List SSCL-16 (lifetime version); (2) repeated measurements over 5 weeks assessing the time course of improvement by the Hamilton Depression Scale HAM-D and the Positive and Negative Syndrome Scale PANSS, along with medications and adverse side effects through the Medication and Side Effects Inventory MEDIS; and (3) the collection of blood samples from which DNA and serum were extracted. Polypharmacy was by far the most common treatment regimen (85%) in this study. On average, patients received 4.50 ± 2.68 medications, consisting of 3.30 ± 1.84 psychotropic drugs, plus 0.79 ± 1.13 medications that alleviate adverse side effects, plus 0.41 ± 0.89 other somatic medications. The treating psychiatrists appeared to be the main determining factor in this context, while «previous history» and «severity at baseline» played a minor role, if at all. Adverse drug reactions were found to be an inherent component of polypharmacy and tended to have a 2–3 times higher incidence compared to monotherapy. Severe adverse reactions could not be attributed to a particular drug or drug combination. Rather, the empirical data suggested that severe side effects can be triggered by virtually all combinations of drugs, provided patients have a respective vulnerability. In terms of efficacy, there were no advantages of polypharmacy over monotherapy. The results of this study underlined the fact that polypharmacy regimens are not equally suited for every patient. Specifically, such regimens appeared to have a negative impact on treatment outcome and to obfuscate the “natural” time course of recovery through a multitude of interfering factors. Evidence clearly speaks against starting just every therapeutic intervention in psychiatry with a combination of psychopharmaceuticals. We think that it is time for psychiatry to reconsider its treatment strategies, which are far too one-sidedly fixated on psychopharmacology and pay far too little attention to alternative approaches, especially in mild cases where psychotherapy without concurrent medication should still be an option. Also, regular exercises and sports can definitely be an effective therapeutic means in a considerable number of cases. General practitioners (GPs) are particularly in demand here.
Highlights
Over the past two decades, stress-induced mental health problems such as psychosomatic disturbances, burn-out conditions, social anxiety, or depressive and schizophrenic disorders were on the rise globally, significantly contributing to the burden of disability and mortality, while reducing quality of life
About 15 years ago, we found in a cross-comparison of five antidepressants (n = 2245) responder rates between 47.5% and 60.9% under monotherapy [2], while the responder rates under antipsychotics lay in the range of some 40% [7]
From our previous study of 2,848 patients comparing the onset of action of 7 different antidepressants and placebo [2], we have learned that adverse side effects start with the beginning of the medication, reach their maximum on the 10th day of treatment, and slowly subside, probably due to habituation effects
Summary
Over the past two decades, stress-induced mental health problems such as psychosomatic disturbances, burn-out conditions, social anxiety, or depressive and schizophrenic disorders were on the rise globally, significantly contributing to the burden of disability and mortality, while reducing quality of life. Mental health problems account for 21.2% of years lived with disability [1]. Though effective, are incomplete since all treatment options are non-causal, so that, for example, antidepressants and antipsychotics that differ greatly in their biochemical design and primary site of pharmacological action display virtually the same insufficient efficacy [2]. There is no long-term cure for a substantial proportion of patients: for example, for 50–60% of patients with schizophrenic disorders (e.g., [3]), and for 35–50% of patients with major depression (e.g., [4, 5]). A solution to this unsatisfactory situation is not to be expected in the near future
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