Antipsychotic polypharmacy appears to be a common but costly practice whose
effectiveness is not supported by evidence, according to two reports in the
January issue of Psychiatric Services.
At the state-hospital level, however, the practice can be significantly
curtailed if hospital leadership focuses its attention on reviewing
prescribing patterns, according to one of those reports.
Researchers at the Neuroscience Education Institute in Carlsbad, Calif.,
analyzed California Medicaid fee-for-service pharmacy claims from May 1999
through August 2000 for patients who received risperidone, olanzapine, or
Of the 116,114 patients who received at least one of these agents, 4.1
percent received a combination regimen. Polypharmacy was the most expensive
form of second-generation antipsychotic use, costing up to three times more
per patient than monotherapy, according to Stephen Stahl, M.D., Ph.D., an
adjunct professor of psychiatry at the University of California, San Diego,
and Meghan Grady, senior medical writer at the Neuroscience Education
They found that the average amount paid per patient receiving just one
antipsychotic medication in the Medi-Cal program (the state's Medicaid
program) was $2,382, compared with $7,536 per patient receiving two or more
antipsychotic medications for more than 60 days.
"If antipsychotic polypharmacy were more effective than monotherapy,
this practice may actually reduce total costs despite the higher pharmacy
costs," Stahl and Grady said. "However, there are currently no
data available to support the effectiveness of antipsychotic polypharmacy.
Thus, there is no reason to believe that antipsychotic polypharmacy would
reduce total costs."
A second paper in Psychiatric Services reported the effectiveness
of a medication review by hospital administrators who actively focused
attention on antipsychotic polypharmacy in an effort at re-education.
Vijayalakshmy Patrick, M.D., a clinical associate professor of psychiatry
at the University of Medicine and Dentistry of New Jersey, and colleagues
reported on an initiative undertaken by psychiatrists and hospital
administrators at an unnamed 570-bed state psychiatric hospital in the
northeastern United States aimed at reducing antipsychotic polypharmacy.
Baseline prescribing practices were gathered for 14 psychiatrists at the
hospital in May 2001. An initial educational program— including case
discussions, consultations with psychiatrists, and psychopharmacology
seminars—did not produce a decline in polypharmacy at follow-up in
November of that year.
At that point, a new chief of psychiatry met individually with each
psychiatrist to compare his or her antipsychotic prescribing data with that of
anonymous peers and urged each to reduce polypharmacy prescribing by 10
percent. Psychiatrists were assured that results would not influence
performance evaluations, according to the report.
A follow-up review in August 2002 found that 127 patients treated by the 14
psychiatrists were receiving antipsychotic polypharmacy compared with 197
patients in November 2001.
The largest subgroup had been receiving "mixed polypharmacy,"
the use of a first-generation agent plus a second-generation agent. That group
also decreased significantly, from 165 patients in November 2001 to 106 in
Of the 14 psychiatrists, 13 reduced their use of polypharmacy, and eight
met the goal of decreasing polypharmacy by at least 10 percent.
"The performance improvement strategy was noteworthy because it did
not include sanctions or compromise anonymity, but relied solely on the chief
of psychiatry's personal expression of expectations along with provision of
individual data for comparison," the report pointed out.
In an interview with Psychiatric News, Patrick said that monthly
medication reviews typically do not address whether polypharmacy is necessary.
But she emphasized that the use of multiple medications is not supported by
evidence and may take the place of useful nonpharmacologic interventions.
Though outcome data on patients who switched from polypharmacy to
monotherapy were not reported, Patrick said there were no adverse effects
She said that because of the chronicity of severe psychiatric illness and
frequent medical comorbidity, there are times when polypharmacy is necessary.
But she added that in her experience, she had never known a patient to get
worse after switching from polypharmacy to monotherapy, especially when other
treatment modalities are combined.
Patrick said that the critical factors in the follow-up intervention were
the focused attention of leadership and the availability of anonymous
comparison data with peers. "Initially, we talked about polypharmacy,
and psychiatrists were well aware of the incidence, but we couldn't make a
change despite the education," she said.
"An Initiative to Curtail the Use of Antipsychotic
Polypharmacy in a State Psychiatric Hospital" is posted online at<http://ps.psychiatryonline.org/cgi/content/full/57/1/21>."
High-Cost Use of Second-Generation Antipsychotics Under California's
Medicaid Program" is posted at<http://ps.psychiatryonline.org/cgi/content/full/57/1/127>.▪