Polypharmacy in schizophrenia - therapeutic option or a sign of despair?

Abstract

International guidelines on schizophrenia and worldwide experts in psychiatry recommend and insist on monotherapy with an antipsychotic medication for schizophrenic patients. Studies about the clinical practice of these guidelines show that all over the world most schizophrenia patients receive two or more antipsychotics. Further more combinations with antidepressants, mood stabilizers or benzodiazepines is also common. Regarding to local national differences polypharmacy rates are increasing and achieve rates between 50 and 90% of schizophrenic patients, exhibiting therefore a major international trend towards polypharmacy. Although in some cases combination therapy brings advantages, such as enhancing or speeding up the antipsychotic effect, there are still a lot of disadvantages in a polypharmacy treatment regiment, such as interactions of the drugs being involved, the greater risk of adverse reactions and the lack of compliance to treatment regiment. Small, randomised controlled studies with regard to antipsychotic combination therapy exist. In summary they exhibit a positive outcome for combinations of antipsychotics with different receptor profile. Altogether according to the study results combinations can be divided in irrational (e.g. clozapine and quetiapine), and rational ones, which provide a greater efficacy (e.g. clozapine and amisulpirid). Augmentation with antidepressant agents in case of persisting negative symptoms and with mood stabilizers in patients with additional affective symptoms can be recommended. Further randomised controlled studies are necessary to recommend combination strategies on a higher level of evidence for treatment resistant schizophrenia patients. In the speech given, I would try to give you an overview and discuss current data and trends in combining antipsychotic or other psychotropic treatment in schizophrenia.