Thank you for reporting on the results of a survey concerning the
California Medicaid program in the March 17 article "Antipsychotic
Polypharmacy: Value for Money?" The survey found that antipsychotic
polypharmacy costs three times as much as monotherapy.
The scope of the polypharmacy problem is widespread especially in state
psychiatric facilities. Even though cost is an important aspect of management
in this era of managed care, experience has shown that doctors are usually
defensive about their prescribing practices when the challenge is based on
Considering that a significant number of patients in state psychiatric
facilities may be treatment resistant, global condemnation of antipsychotic
combination may be misdirected. While regular audit and individual comparison
with anonymous peers is critical to monitor practices as compared with
existing standards, it must be coupled with regular educational programs.
Unlike the broad-based programs that were found to be ineffective by some
of the hospitals featured in the article, however, effective educational
programs must be specifically focused on evidence-based prescribing practices.
Such programs must also include evidence-based practical algorithms in cases
in which rational combination is justified. For example, augmentation might be
necessary under these conditions: when a patient fails to respond to adequate
antipsychotic trials, especially with clozapine; in some instances of failed
cross-taper of antipsychotics; and the addition of a first-generation
antipsychotic to a second-generation antipsychotic when a patient is
experiencing agitation during acute treatment of psychosis.