This is another short Clinical Problems in Consultation Psychiatry (CPCP), this time on polypharmacy in psychiatry, which can be a potentially deadly problem. It doesn’t mean that polypharmacy is always wrong. In fact, in general medicine it’s not an unusual practice. It’s true that in psychiatry, I see a fair number of cases in which two, sometimes three antipsychotics being used for the same indication and sometimes two or more have the same mechanism of action. Some patients complain about feeling like a zombie from even one psychiatric drug, let alone several.
I ran across this article published in the Harvard Review Psychiatry that outlines a possible systematic approach to “diagnosing” psychiatric polypharmacy and offers guidelines about simplifying when it’s indicated. Emphasizing safety for the patient is the real goal here, not criticizing individual prescribing patterns per se that may involve rational polypharmacy in some cases.
When I think about this issue, I realize it involves all of the core competencies–the whole pizza.
The authors of this paper really almost maps to the core competencies, which are often deployed simultaneously in these situations:
Medical Knowledge: Many clinicians pride themselves on their receptor chemistry knowledge, although the quote from Churchill applies, “However beautiful the strategy, you should occasionally look at the results”–Sir Winston Churchill.
Patient Care: Part of diagnosing psychiatric polypharmacy involves a careful consideration of not only what disease the patient has but what kind of patient has the disease, as Sir William Osler said.
Systems-based practice: This is also part of the differential diagnosis of polypharmacy, as you’ll see, because our health care system drives some of the decisions about how many drugs to prescribe for patients.
Practice-based learning: Learning about when psychiatric polypharmacy might be considered rational can be discovered by a careful search of the medical literature.
Interpersonal skills and communication skills: Talking with patients, families, and colleagues involves good listening skills and taking the time to understand before trying to be understood.
Professionalism: Always hard to define either in terms of behaviors and ideals, professionalism in this case might be respecting a colleague’s decision to use polypharmacy while remaining vigilant for potential harms to patients–First Do Harm.
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Proposed Definition of Polypharmacy
The use of more than one medication to treat the same psychiatric indication which may be unnecessarily complicated
Differential Diagnosis of Psychiatric Polypharmacy
What sort of disease?
What sort of patient ?
What sort of doctor?
What sort of society?
Pharmacological hedonism or Calvinism
Early or late adopter
Self-image as powerful healer
Fear of negative patient satisfaction ratings
Market-based system driven by consumer choice
Fragmented health care system
Outside pressures (other stakeholders such as managed care)
Checklist Approach: Differential Diagnosis
Is the disorder optimally managed, considering both psychotherapy and medication?
What’s the patient’s contribution to the regimen?
What’s the clinician’s contribution to the regimen?
What is the contribution of the health care system to the regimen?
Self-Reflection and Review not Requiring Permission from Others
Do I know what I’m prescribing and why?
Can I quantify short and long term goals and outcomes?
Is my “beautiful strategy” yielding good results or is it leading to zombification of my patients?
Action Planning Requiring Permission from Others?
Is there any easy way to simplify the medication list right now?
What do I need to teach the patient in order to facilitate my understanding of his/her readiness to change and what it might take to foster evolution in a more healthy direction?
Which interpersonal relationships are important influences on my patient’s choices and what do I need to learn about the cultural, legal, political, and economic pressures that I can influence–or not?
Take Home Points
Psychiatric polypharmacy, while not necessarily always bad, is increasing and can be harmful or deadly to patients if clinicians exercise it thoughtlessly
A systematic self-reflective inquiry to diagnose polypharmacy can uncover unexamined motives and external pressures leading to the practice of polypharmacy
Changes in attitude and communication skills are important for broaching the topic with patients and other stakeholders while being mindful of the systems context of psychiatric polypharmacy
“Let me tell you something… zombies need to get their big boy pants on.”–Donald Trump.
Freudenreich, O., et al. (2012). “Psychiatric polypharmacy: a clinical approach based on etiology and differential diagnosis.” Harv Rev Psychiatry 20(2): 79-85.
Polypharmacy is common clinical practice in the United States for many psychiatric conditions and for many reasons. In this article we encourage clinicians to use the familiar practice of differential diagnosis to systematically identify etiological factors contributing to polypharmacy. We offer a clinical approach based on (1) reviewing the four main factors responsible for polypharmacy (the disease, the patient, the physician, and society) and (2) answering two questions about optimizing medication regimens (What can I do without explicit permission from the patient or others? What can I do with permission from them?). We contend that all physicians share a professional responsibility for prescribing medications judiciously because unnecessary prescribing exposes patients to unwarranted risks and squanders valuable and scarce resources. Psychiatrists can ask themselves a Kantian question: would my way of prescribing lead to good, socially acceptable outcomes if followed by all physicians treating similar patients?