CPCP: Psychiatric Polypharmacy

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.

Core Competency Pizza
Core Competency 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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“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?

One thought on “CPCP: Psychiatric Polypharmacy

  1. Jim,

    Polypharmacy is something that has been with us since the old days. When I was a PRO reviewer for Medicare hospitalizations in the 1980s, 1990s, and early 2000s, our standard definition was “no more than one medication from a particular class”. That definition has not stood the test of time in that there are now clinical trials showing that you can augment one antidepressant with another. Most bipolar experts acknowledge that in most of their patients it requires more than one medication for stabilization. I wonder if overprescribing may be a more useful concept. I would define it as basically prescribing too much medicine either based on diagnosis, sheer amount of a single medication, or too many different medications. I tried to capture it in the bubble diagram at this link:


    There is also a link to overprescribing that pulls up multiple documents.

    One of the problems here is that there is also a link to the insidious notion that we can improve human performance by taking more medications and supplements. There has been surprisingly little research to suggest that is true and some research to show it is probably not true. It is fairly common these days to encounter people with a positive psychiatric review of systems who are looking for polypharmacy on day one. Many have done their own research, and talk in a seemingly authoritative way about why they need pills for depression, anxiety, insomnia, ADHD (of course), and fatigue. Every psychiatrist and trainee needs to be able to discuss with them why that is not a good idea. The bubble diagram assumes that physicians are able to set internal limits on themselves and limits on demands from patients and significant others.

    George Dawson, MD

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