Use Of Multiple Antipsychotics Research Articles

A comparison of clinical characteristics and course predictors in early- and childhood-onset schizophrenia.

The aim of this study was to compare the clinical characteristics of childhood-onset schizophrenia (COS) and early-onset schizophrenia (EOS) during the first- episode psychosis and the stable period, to examine psychopharmacological treatment approaches, and to investigate potential predictive factors for prognosis. Demographic, clinical, and psychopharmacological therapy data for 31 patients diagnosed with COS and 66 with EOS were retrieved from the file records in this multicenter study. Symptom distribution and disease severity and course were evaluated twice, in the acute psychotic stage and in the latest stable phase, during follow-up using the positive and negative syndrome scale (PANSS) and clinical global impression (CGI) scales. A statistically significant difference was observed between the groups' CGI improvement rates and median last stable stage PANSS positive, negative, and general psychopathology symptom scores (p = .005, p = .031, p = .005, and p = .012, respectively). Premorbid neurodevelopmental disorder and obsessive-compulsive disorder and comorbidities were more common in the COS group (p = .025 and p = .030, respectively), and treatment required greater multiple antipsychotic use in that group (p = .013). When the independent variables affecting the difference between pre- and post-treatment PANSS scores were examined using linear regression analysis, the model established was found to be statistically significant (F = 5.393; p = .001), and the group variable (p = .024), initial disease severity (p = .001), and socioeconomic level (p = .022; p = .007) emerged as predictive factors for the disease course. Although early diagnosis and treatment is an important factor in improving prognosis in schizophrenia, more specific predictors for schizophrenia need to be identified. Additionally, preventive programs and pharmacological methods need to be developed in children with neurodevelopmental problems, particularly those from low socioeconomic status families.

Antipsychotic Polypharmacy-Related Cardiovascular Morbidity and Mortality: A Comprehensive Review.

Schizophrenia is a psychotic disorder that exists at the more extreme end of a spectrum of diseases, and significantly affects daily functioning. Cardiovascular adverse effects of antipsychotic medications are well known, and include changes in blood pressure and arrhythmias. Sudden cardiac death is the leading cause of death worldwide, and antipsychotic medications are associated with numerous cardiac side effects. A possible link exists between antipsychotic medications and sudden cardiac death. Common prescribing patterns that may influence cardiovascular events include the use of multiple antipsychotics and/or additional drugs commonly prescribed to patients on antipsychotics. The results of this review reflect an association between antipsychotic drugs and increased risk of ventricular arrhythmias and sudden cardiac death by iatrogenic prolongation of the QTc interval. QTc prolongation and sudden cardiac death exist in patients taking antipsychotic monotherapy. The risk increases for the concomitant use of specific drugs that prolong the QTc interval, such as opioids, antibiotics, and illicit drugs. However, evidence suggests that QTc intervals may not adequately predict sudden cardiac death. In considering the findings of this narrative review, we conclude that it is unclear whether there is a precise association between antipsychotic polypharmacy and sudden cardiac death with QTc interval changes. The present narrative review warrants further research on this important potential association.

Electrocardiographic abnormalities and psychotropic polypharmacy in schizophrenia and schizoaffective disorders

Background: Sudden cardiac death (SCD) is a significant cause for increased mortality in people with schizophrenia and schizoaffective disorders. Cardiac arrhythmia is one cause of SCD. Electrocardiographic (ECG) abnormalities predictive of arrhythmias are associated with antipsychotic drug use. Method: This chart audit examined the types and frequency of ECG abnormalities (ECG-Abs) in 169 patients with schizophrenia and schizoaffective disorder in a long-stay inpatient unit. We examined the association of ECG-Abs with demographic details and psychotropic drug prescription using chi-square test, Fisher’s Exact test, independent two-sample t-test, Pearson’s correlation, and one-way ANOVA. Results: Eighty-eight patients (52.1%) recorded at least one ECG-Ab, and 20.7% had two or more ECG-Abs. The use of multiple antipsychotics, with or without other psychotropic drugs, did not associate significantly with the presence or number of ECG-Abs. Conclusion: A significant proportion of patients with schizophrenia and schizoaffective disorder have ECG-Abs other than prolonged QTc interval, which can predispose them to cardiac arrhythmias. The abnormalities were not limited to patients on psychotropic polypharmacy. ECG evaluation is indicated for all patients and should consider various electrical abnormalities to identify arrhythmia risk.

Exploring a Safety Signal of Antipsychotic-Associated Pneumonia: A Pharmacovigilance-Pharmacodynamic Study.

An association between antipsychotic drugs and pneumonia has been demonstrated in several studies; however, the risk for pneumonia caused by specific antipsychotics has not been extensively studied. The underlying mechanism is still unknown, and several receptor mechanisms have been proposed. Therefore, using a combined pharmacovigilance-pharmacodynamic approach, we aimed to investigate safety signals of US Food and Drug Administration (FDA)-approved antipsychotics for reporting pneumonia and the potential receptor mechanisms involved. A disproportionality analysis was performed to detect a signal for reporting "infective-pneumonia" and "pneumonia-aspiration" and antipsychotics using reports submitted between 2004 and 2019 to the FDA adverse events spontaneous reporting system (FAERS) database. Disproportionality was estimated using the crude and the adjusted reporting odds ratio (aROR) and its 95% confidence interval (CI) in a multivariable logistic regression. Linear regressions investigated the relationship between aROR and receptor occupancy, which was estimated using in vitro receptor-binding profiles. Safety signals for reporting infective-pneumonia were identified for clozapine (LL = 95% 3.4, n = 546 [aROR: 4.8]) as well as olanzapine (LL = 95% 1.5, n = 250 [aROR: 2.1]) compared with haloperidol, while aRORs were associated with higher occupancies of muscarinic receptors (beta = .125, P-value = .016), yet other anti-muscarinic drugs were not included as potential confounders. No safety signals for reporting pneumonia-aspiration were detected for individual antipsychotics. Multiple antipsychotic use was associated with both reporting infective-pneumonia (LL 95%: 1.1, n = 369 [aROR:1.2]) and pneumonia-aspiration (LL 95%: 1.7, n = 194 [aROR: 2.0]). Considering the limitations of disproportionality analysis, further pharmacovigilance data and clinical causality assessment are needed to validate this safety signal.

Multiple antipsychotics use in patients with schizophrenia: Why do we use it, what are the results from patient follow-ups?

In this study, the rates of antipsychotic polypharmacy, factors affecting combined drug use, the relationship between antipsychotic polypharmacy as it relates to duration of hospitalization and re-hospitalization, and treatment compliance were evaluated in schizophrenia patients. The study data was obtained between January 1, 2017 and December 31, 2017 by examining the files of all patients who were hospitalized in Ondokuz Mayıs University Faculty of Medicine Hospital, Ankara Numune Training and Research Hospital, Ankara Gulhane Training and Research Hospital psychiatric services. The inpatients' drug prescriptions at discharge and after one-year outpatient follow-up, as well as treatment compliance and re-hospitalization, were examined. The mean duration of illness was 109.3 ± 109.7 months, and the mean duration of hospitalization was 24.6 ± 19.1 days. For a total of 599 patients, multiple antipsychotic medication was used in 21.2% of hospitalizations. 11.2% of patients using single antipsychotic and 14.2% of patients using multiple antipsychotics were re-hospitalized within one year (X 2 :0.830, p:0.362). Disease duration (Z:-3.654, p < 0.001) and duration of hospitalization (Z:-3.333, p < 0.001) were found to be longer in multiple antipsychotic users. 37.8% of the patients used a depot antipsychotic. There was no significant difference between depot antipsychotic use and oral antipsychotic use as it related re-hospitalization rates. As a conclusion, multiple antipsychotic use has reduced in Turkey. Contrary to popular belief, the use of multiple antipsychotics does not shorten, but rather may prolongs hospitalization, and it has no effect in reducing re-hospitalization. Drug combinations are generally used together with a depot treatment, clozapine treatment is preferred less frequently in combinations, clinicians have proven effectiveness of the drug combination they prefer, and they should give priority to the treatments recommended in treatment guidelines.

Prescribing antipsychotics in child and adolescent psychiatry: guideline adherence

Antipsychotics are often prescribed to children and adolescents, mostly off-label. We aimed to assess adherence to recommendations of guidelines for antipsychotic prescription. We reviewed 436 medical records from 155 clinicians from 26 clinics within three Dutch child and adolescent psychiatry organizations (n = 398 outpatient, n = 38 inpatient care). We assessed target symptoms, diagnostic process, prior and concomitant treatment, and consideration of contra-indications. Multiple logistic regression assessed the role of age, sex, and psychiatric diagnosis on adherence to three main recommendations: to (1) prescribe antipsychotics only after other treatments proved insufficient, (2) always combine antipsychotics with psychosocial interventions, and (3) not prescribe multiple antipsychotics simultaneously. Most patients received off-label antipsychotics. Main target symptoms were inattention/hyperactivity (25%), aggression (24%), and other disruptive behaviors (41%). Most patients underwent diagnostic evaluation before the first prescription; however, screening of contra-indications was low (0.2–19%). About 84% had previously received psychosocial treatment and 48% other psychoactive medication, but 9% had not received any treatment. Notably, only 37% continuously received concomitant psychosocial treatment. Simultaneous use of multiple antipsychotics occurred in 3.2%. Younger children were at higher risk of non-adherence to guideline recommendations regarding prior and concomitant treatment, children with autism spectrum disorder or attention-deficit/hyperactivity disorder more likely not to receive concomitant psychosocial treatment. Sex did not significantly affect adherence. Our findings implicate insufficient adherence to important recommendations regarding antipsychotic use in children and adolescents. Especially younger children are at higher risk of receiving suboptimal care. There is an urgency to consistently offer psychosocial interventions during antipsychotic treatment.

A Neuroleptic Malignant Syndrome Without Rigidity.

Neuroleptic malignant syndrome (NMS) is an uncommon but potentially lethal idiosyncratic reaction which may emerge in the aftermath of the treatments with neuroleptics demonstrating itself with the symptoms of altered consciousness, high fever, impaired autonomic functions, and muscle rigidity. Although various risk factors have been identified for NMS, its etiology is not completely known. The mortality and morbidity related with NMS could be reduced by early diagnosis, interruption of the neuroleptics used within a short period and aggressive treatment. Our case is different from general NMS cases due to lack of rigidity. A NMS case which developed within a short time in the aftermath of multiple antipsychotic use and wherein no rigidity was observed shall be discussed in this case report.

Physical Health and Drug Safety in Individuals with Schizophrenia.

While antipsychotic medications are the mainstay of therapy for individuals with schizophrenia and psychotic disorders, their use is associated with adverse effects on physical health that require the attention and care of prescribers. We used the ADAPTE process to adapt existing guideline recommendations from the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the dosing of antipsychotics and antipsychotic polypharmacy, screening for adverse effects of antipsychotics, and management of metabolic and extrapyramidal side effects to the Canadian context. Prescribers are encouraged to use the lowest effective dose and to avoid the routine use of multiple antipsychotics. Scheduled monitoring of body mass index, waist circumference, blood pressure, glucose, lipids, prolactin, electrocardiograms, and extrapyramidal symptoms is recommended. Lifestyle interventions are recommended to mitigate antipsychotic-induced weight gain. Prescribers should follow Canadian guidelines on the treatment of obesity, dyslipidemia, and diabetes. Recommendations on antipsychotic drug choice are made for users particularly concerned about extrapyramidal symptoms. Careful monitoring and attention by prescribers may mitigate adverse effects associated with antipsychotic medications.

Prevalence of obesity and diabetes in patients with schizophrenia.

AIMTo compare the prevalence of diabetes in patients with schizophrenia treated at a community mental health center with controls in the same metropolitan area and to examine the effect of antipsychotic exposure on diabetes prevalence in schizophrenia patients.METHODSThe study was a comprehensive chart review of psychiatric notes of patients with schizophrenia and schizoaffective disorder treated at a psychosis program in a community mental health center. Data collected included psychiatric diagnoses, diabetes mellitus diagnosis, medications, allergies, primary care status, height, weight, body mass index (BMI), substance use and mental status exam. Local population data was downloaded from the Centers for Disease Control Behavioral Risk Factor Surveillance System. Statistical methods used were χ2 test, Student’s t test, general linear model procedure and binary logistic regression analysis.RESULTSThe study sample included 326 patients with schizophrenia and 1899 subjects in the population control group. Demographic data showed control group was on average 7.6 years older (P = 0.000), more Caucasians (78.7% vs 38.3%, P = 0.000), and lower percentage of males (40.7% vs 58.3%, P = 0.000). Patients with schizophrenia had a higher average BMI than the subjects in the population control (32.11, SD = 7.72 vs 27.62, SD = 5.93, P = 0.000). Patients with schizophrenia had a significantly higher percentage of obesity (58.5% vs 27%, P = 0.000) than the population group. The patients with schizophrenia also had a much higher rate of diabetes compared to population control (23.9% vs 12.2%, P = 0.000). After controlling for age sex, and race, having schizophrenia was still associated with increased risk for both obesity (OR = 3.25, P = 0.000) and diabetes (OR = 2.42, P = 0.000). The increased risk for diabetes remained even after controlling for obesity (OR = 1.82, P = 0.001). There was no difference in the distribution of antipsychotic dosage, second generation antipsychotic use or multiple antipsychotic use within different BMI categories or with diabetes status in the schizophrenia group.CONCLUSIONThis study demonstrates the high prevalence of obesity and diabetes in schizophrenia patients and indicates that antipsychotics may not be the only contributor to this risk.

Prevalence of multiple antipsychotic use and associated adverse effects in Australians with mental illness.

This article analyzes the prevalence of use of concurrent multiple antipsychotics and high dosage treatment in people with mental illness, to assess the burden of antipsychotic drug-related side-effects associated with multiple use, and to identify strategies shown to reduce antipsychotic polypharmacy. Literature reviewed was sourced from MEDLINE, Embase, CINAHL, InformIT, PsycINFO, International Pharmaceutical Abstracts, Cochrane Library database and Joanna Briggs Institute databases to identify Australian studies published between January 2000 and February 2015. Studies that reported prevalence of multiple antipsychotic use or addressed the issue of antipsychotic drug-related side-effects were included. Systematic reviews, randomized controlled trials, and observational pre-post studies of Australian and international interventions aiming to reduce multiple antipsychotic use in mental health settings were also identified. Nineteen studies reporting prevalence of multiple antipsychotic use were identified. The proportion of patients taking more than one antipsychotic ranged from 5 to 61%. Of the studies assessing dosages used, between one-third and one-half of all patients taking multiple antipsychotics received doses higher than recommended. Data from one national study reported that people taking multiple antipsychotics were more likely to experience at least one side-effect in comparison to consumers taking a single antipsychotic (90 verses 80%).International evidence of direct trials of conversion from treatment regimens involving multiple antipsychotics to those based on monotherapy show that between 50 and 75% of people with serious mental illness could be successfully converted to single-agent treatment, with up to 25% obtaining an improvement in health and the remaining 50% staying well managed. Use of multiple antipsychotics is common among Australian people with mental illness, despite guidelines recommending that only one antipsychotic should be used in most cases. People taking more than one antipsychotic at a time are more likely to experience side-effects, and to receive higher than recommended antipsychotic doses. Direct trials that aimed to reduce multiple antipsychotic use suggest it is possible to effectively reduce therapy in the majority of people without worsening outcomes. Simple educational programmes targeting health professionals have not been found to be effective; however, complex multifaceted programmes and quality improvement programmes have demonstrated effect.

Risks and benefits of rapid clozapine titration

Clozapine is often considered the gold standard for the treatment of schizophrenia. Clinical guidelines suggest a gradual titration over 2 weeks to reduce the risks of adverse events such as seizures, hypotension, agranulocytosis, and myocarditis. The slow titration often delays time to therapeutic response. This raises the question of whether, in some patients, it may be safe to use a more rapid clozapine titration. The following case illustrates the potential risks associated with the use of multiple antipsychotics and rapid cloza-pine titration. We present the case of a young man with schizophrenia who developed life threatening neuroleptic malignant syndrome (NMS) during rapid clozapine titration and treatment with multiple antipsychotics. We were unable to find another case in the literature of NMS associated with rapid clozapine titration. This case is meant to urge clinicians to carefully evaluate the risks and benefits of rapid clozapine titration, and to encourage researchers to further evaluate the safety of rapid clozapine titration. Rapid clozapine titration has implications for decreasing health care costs associated with prolonged hospitalizations, and decreasing the emotional suffering associated with uncontrolled symptoms of psychosis. Clozapine is considered the most effective antipsychotic available thus efforts should focus on developing strategies that would allow for safest and most efficient use of clozapine to encourage its utilization for treatment resistance schizophrenia.

Prescription profile of antipsychotics in inpatients with psychotic disorders

IntroductionPrevious studies of prescribing in psychiatric services have identified the relatively frequent use of combined antipsychotics in schizophrenia.Aims– To analyze the proportion of patients treated with more than one antipsychotic;– to study clinical as sociodemographic variables associated with types of prescription.MethodsRetrospective descriptive study of treatment prescribed to psychiatric inpatients treated in an acute care unit of Psychiatry Service in a large teaching hospital during a period of 3 years. Consecutively admitted inpatients receiving concurrent antipsychotics were compared with those treated with a single antipsychotic. Prescription drug records at discharging were revised, n = 263.ResultsFrom the total sample, 61% received more than one antipsychotic. The most common types of combinations were atypical plus a typical antipsychotic followed by two atypical antipsychotics, being less frequent combination of three or more antipsychotics. There were 19 different drug combinations. Concurrent antipsychotics were most frequently prescribed in schizophrenia and schizoaffective disorder. Patients with more previous episodes of illness received more frequently concurrent antipsychotics than patients with low number of previous episodes of illness (P &lt; 0.03). Patients with longer time of hospitalization, and age between 30 and 50 years were treated more frequently with several antipsychotics. Analysis with other variables is presented in the study.ConclusionsThere is a significant difference in the strategies of treatment with antipsychotics depending on diagnosis and number of previous episodes of illness. The concurrent use of multiple antipsychotics in psychiatric inpatients appears to be a response to treatment resistance and is frequent in schizophrenic patients.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Factors Associated with Costs of Hospitalization of Severely Mentally Ill Patients

Background: Efforts to contain costs associated with general medical care include particular efforts for psychiatric disorders. Hospitalization represents the largest component of costs for psychiatric care and there is growing interest in balancing clinical needs against limiting costs of inpatient psychiatric care of patients with severe mental illnesses. This study aimed to evaluate clinical factors associated with actual costs of inpatient psychiatric care. Method: We evaluated a cohort of 589 hospitalized psychiatric patients with severe mental illnesses at a nonprofit, university-affiliated psychiatric hospital for factors associated with annualized total costs of inpatient care over a three-year period, using bivariate and multivariate analyses. Results: As expected, days-hospitalized was the major determinant of total costs of hospital care. In addition, several clinical and treatment factors also were associated significantly and independently with costs in multivariate modeling. These included presence of psychosis, electroconvulsive treatment, specialist consultations, use of multiple antipsychotics or of clozapine, and being discharged to a supervised living arrangement, but not sex, age, marital status, employment, or substance abuse. Discussion: As expected, costs of psychiatric hospitalization were dominated by per-diem charges, but also influenced by other, potentially modifiable treatment factors generally associated with more severe psychotic illnesses. The study is based on actual costs rather than on insurer-reimbursements and a large study-sample, though at a single institution. Specific factors identified encourage focusing on patient characteristics associated with greater costs and redoubled efforts to apply and improve alternative, cost-effective interventions such as partialhospital and intensive outpatient treatment.

Psychopharmacological treatment for schizophrenia: less is more.

BackgroundAntipsychotic polypharmacy in the treatment of schizophrenia is more common in China and other Asian countries than in Western countries. The reasons for this are unclear, but it may be related to an unsubstantiated belief among clinicians that multiple medications are more likely to achieve the desired clinical outcome. Antipsychotic medications are the mainstay of treatment for individuals with schizophrenia, but the use of antipsychotic polypharmacy and of high dosages of antipsychotic medication are associated with substantially increased risks without conferring improved clinical outcomes. It is generally accepted that high dosages of antipsychotic medications and the simultaneous use of multiple antipsychotics are associated with an increased prevalence, duration, and severity of adverse drug effects. More recent evidence also suggests that antipsychotic polypharmacy and the associated high overall dosage of antipsychotic medication lead to excessive striatal D2 receptor occupation (resulting in tolerance and drug withdrawal problems) and exacerbation of the impaired synaptic plasticity seen in schizophrenia (magnifying the cognitive impairment associated with the condition). Clinicians need to apply the ‘less is more’ principle in the psychopharmacological treatment of schizophrenia.

Amygdalohippocampal neuroplastic changes following neuroleptic treatment with quetiapine in first-episode schizophrenia

Schizophrenia is a severe, debilitating, chronic disease that is accompanied by morphologic changes within the brain. However, it is unclear to what extent alterations of grey and white matter in schizophrenia are linked to the disease itself, or whether they are a consequence of neuroleptic treatment. Typical and atypical antipsychotics exert differential effects on brain structure. Moreover, atypical antipsychotics may have distinct profiles with respect to grey matter in schizophrenic patients. Findings on drug-induced grey matter changes are heterogeneous due to variation in stage of illness, duration of treatment and use of multiple antipsychotics. Using voxel-based morphometry applied to high-resolution magnetic resonance images, we show that monotherapy with the atypical agent quetiapine (mean daily dose = 445 mg ± 200 s.d.) may induce structural brain changes in first-episode schizophrenia patients (N = 20) within 21 d of treatment. Specifically, we demonstrate longitudinal macroscopic changes (i.e. grey matter increases) in the left amygdalohippocampal region that were predicted by drug plasma levels but not daily doses. These structural alterations were accompanied by a clinical improvement of schizophrenic symptoms. Comparison with healthy controls (n = 30) showed that grey matter amount in the respective amygdalar region was significantly reduced in unmedicated first-episode schizophrenia patients. These findings suggest that drug-induced neuroplastic changes in schizophrenia can occur quickly and are dependent on pharmacokinetics.

A Face-to-face Questionnaire Survey on the Use of Multiple Antipsychotics and the Manifestation of Side Effects in Outpatients with Schizophrenia

We investigated the use of multiple antipsychotics and the manifestation of side effects in outpatients with schizophrenia and compared the results of patients who received 1 antipsychotic (monotherapy) with those of patients who received more than 1 antipsychotic (multidrug therapy). To achieve this, we visited 8 community life-support centers and conducted a face-to-face questionnaire survey with 47 outpatients. Sixteen (34%) of these patients had received monotherapy and 31 (66%), multidrug therapy. Complaints involving the central nervous system, anticholinergic symptoms, metabolic symptoms (weight gain, increase in blood glucose, etc.), and extrapyramidal symptoms were seen across the patients. The average incidence of side effects was 2.2 per person in the monotherapy group and 4.8 in the multidrug-therapy group. The number of nonantipsychotic drugs used concomitantly in the monotherapy group was also smaller than that used in the multidrug-therapy group (2.3 and 5.0 per person, respectively). Further, we analyzed the 47 patients as described above; 20 patients received typical antipsychotics (TA group), 10 patients received atypical antipsychotics (AA group), and 17 patients received both typical and atypical antipsychotics (MIX group). The average incidence of side effects in the TA, AA, and MIX groups was 2.8, 3.2, and 5.5 per person, respectively, and the number of nonantipsychotic drugs used concomitantly was 2.2, 3.2, and 6.1, respectively. On the basis of our results, it can be suggested that monotherapy with an atypical antipsychotic can reduce both the number of nonantipsychotic drugs used concomitantly and the average incidence of side effects.

Antipsychotic medication prescription patterns in adults with developmental disabilities who have experienced psychiatric crisis

Antipsychotic medication rates are high in adults with developmental disability. This study considered rates of antipsychotic use in 743 adults with developmental disability who had experienced a psychiatric crisis. Nearly half (49%) of these adults were prescribed antipsychotics. Polypharmacy was common with 22% of those prescribed antipsychotics taking 2 or more antipsychotics at once. Predictors of multiple antipsychotic use included gender, residence, psychiatric diagnosis and previous hospitalizations. Implications of medication prescriptions to this vulnerable population are discussed.

What Can Large Simple Trials Do for Psychiatry?

What Can Large Simple Trials Do for Psychiatry?

Multiple antipsychotic use associated with metabolic and cardiovascular adverse events in children and adolescents

Multiple antipsychotic use associated with metabolic and cardiovascular adverse events in children and adolescents

Datapoints: Polypharmacy as the Initial Second-Generation Antipsychotic Treatment

Back to table of contents Previous article Next article ColumnFull AccessDatapoints: Polypharmacy as the Initial Second-Generation Antipsychotic TreatmentBrason Lee M.S.W., M.S.Victor Walker B.S.Brason Lee M.S.W., M.S.Search for more papers by this authorVictor Walker B.S.Search for more papers by this authorPublished Online:1 Jul 2008AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Antipsychotic polypharmacy is a debatable practice that continues to occur. Evidence suggests that the likelihood of having a physician office visit that involves antipsychotic polypharmacy may have increased 2.5 times from 1993–1994 to 1999–2000 ( 1 ). This is concerning because use of second-generation antipsychotics has largely replaced that of first-generation antipsychotics ( 2 ), and the number of office visits resulting in an antipsychotic prescription has increased 1.9 times from 1998 to 2002 ( 3 ). Although there is agreement that polypharmacy is generally not recommended, we found few studies that describe when concomitant antipsychotic use might start. To explore the use of multiple antipsychotics as a first-line treatment, we examined California's Medicaid claims data to identify all beneficiaries who filled at least one prescription for a second-generation antipsychotic in 2003. We defined new users as those who had no antipsychotics of any kind in the 183 days before the index prescription. We defined polypharmacy as those with two or more second-generation antipsychotic prescriptions on the date of initiation.Among the 238,550 persons who filled prescriptions for second-generation antipsychotics, 7.0% were considered to be new users of this class. New users were evenly distributed by age, with 38.2% aged 35–54 years. Half were female (51.4%), 45.7% were Caucasian, 17.5% were African American, 17.6% were Hispanic, 11.6% were from another race, and the race was unknown for 7.5%. A total of 3.7% of new users filled a prescription for multiple second-generation antipsychotics. Most users initiated treatment with one second-generation prescription, such as risperidone (39.1%) or olanzapine (35.1%) ( Figure 1 ). Figure 1 Index antipsychotic prescription filled by new users of second-generation antipsychotic medications, 2003Our results should be interpreted cautiously, because we defined new users as those with no antipsychotic prescriptions of any kind in the six months before the index claim. Some patients may not truly be new users and may have had success with polypharmacy at some time in the past. Given these limitations, our findings suggest that antipsychotic polypharmacy may be starting earlier than expected. It is difficult to understand why multiple antipsychotics would be prescribed without a trial of a single agent. We suspect that some physicians may favor multiple antipsychotics as a practice to offset the side effects of the other more potent antipsychotic agents. More studies are needed to examine second-generation antipsychotic polypharmacy.Acknowledgments and disclosuresThe authors thank Patrick Finley, Pharm.D., Paul Perry, Ph.D., Gregory Doe, Pharm.D., and Anura Ratnasiri, M.S., for their contributions. The views expressed in this column are for information and discussion and may not represent the formal policies of the California Department of Public Health or the California Department of Health Care Services. Responsibility for the text and the positions implied in it rest solely with the authors.The authors report no competing interests.Mr. Lee is with the Center for Family Health, California Department of Public Health, 1615 Capitol Ave., MS 8304, P.O. Box 997420, Sacramento, CA 95899-7420 (e-mail: [email protected]). Mr. Walker is with the Center for California Medicaid, California Department of Health Care Services, Sacramento, with which Mr. Lee was affiliated when the study was initiated. Amy M. Kilbourne, Ph.D., M.P.H., and Tami L. Mark, Ph.D., are editors of this column.