Many patients who show up in our emergency rooms or clinics are taking a large number of psychiatric medications. For instance, it is not unusual to see people on several different antidepressants, several different antipsychotics, a mood stabilizer, pain pills, and a sleeping pill. Why? And does this reflect good clinical care?
We want to state up front that we are strong advocates of the appropriate use of medications to treat people who suffer from psychiatric illnesses such as schizophrenia, bipolar disorder, severe depressions, and severe anxiety disorders. When someone is ill with a disabling psychiatric illness, one or a few medications in combination with appropriate psychosocial interventions are often extremely helpful at decreasing or eliminating the painful symptoms. Appropriate medications can be life-saving.
However, we find that we are spending a lot of time teaching psychiatric residents (physicians who are doing 4 years of training after medical school in order to become psychiatrists) how to simplify drug regimens for patients. These days, we frequently encounter patients on 5 or more psychiatric medications (including pain medications). Occasionally, complex combinations of drugs may be useful and understandable, but we believe that this is the exception, not the rule. Why, then, is this "polypharmacy" (the simultaneous use of large numbers of medications) occurring? Here are a few possible reasons:
1. Incorrect diagnosis - Patients frequently report that they have a certain diagnosis - let's say bipolar disorder, for example. Careful evaluation may indicate that they have mild mood fluctuations but not the dramatic symptoms or typical time course of true bipolar disorder (for instance, episodes of very rapid speech and very rapid thoughts, grandiose beliefs of special powers, and very high energy despite little sleep). In other words, mildly exaggerated mood fluctuations are misdiagnosed as bipolar disorder. If a person is not diagnosed correctly and is then treated for an inaccurate diagnosis, the results are usually poor. Often, more medications are added and a vicious cycle begins.
2. Impatience- Most psychiatric drugs take several weeks (or even a month or two) to work. If a person is hospitalized for a psychiatric disorder, our current medical system dictates that he or she must be discharged in a matter of days, not weeks. It is natural for doctors, patients, family members and even third party payers (insurance companies) to want rapid improvement of symptoms. Therefore, in an effort to speed things up, several medications may be started at once or additional medications may be added in rapid succession before the primary medication has had time to work. This may help everyone feel that everything possible is being done. But the biological processes that are initiated by these medications take time to have an impact on symptoms. The brain does not typically respond faster just because multiple drugs are being used simultaneously. The end result might be that the person is prescribed more medications than actually needed with the mistaken belief that this is beneficial.
3. Medications are prescribed inappropriately - Off label use of medications is common (that is, medications are prescribed for reasons not approved by the FDA). Sometimes, such use is appropriate and well justified, meaning that data from well-designed clinical trials support the effectiveness of such use. Far too often, however, psychiatric drugs are prescribed for conditions without data to back up their usefulness. Antipsychotic drugs are powerful medications, but they are not meant to treat typical anxiety or sleep disturbances. Mood stabilizers are helpful for bipolar disorder, but they aren't meant for everyday moodiness. When someone has "conditions" that don't respond to a single medication, more medications are sometimes added in the belief that if one doesn't work, maybe two, three, or even four might. This is faulty logic. Compounding this issue is what we call the "fallacy of partial response." Here, patients sometimes report only a minor improvement in symptoms. In an effort to build upon the partial response, more medications are added, sometimes inappropriately. In this situation, it is important for psychiatrists and patients to have frank and open discussions about the benefits and risks of all treatments being used. When a medication (or other treatment) isn't adding much benefit, discontinuation is often the most appropriate strategy.
4. Many doctors treating the same patient - Patients often have more than one physician. Different doctors may add medications without knowing about other medications that a patient is already taking. Unfortunately, doctors are frequently rushed, and patients may not realize the importance of telling their doctors about medications that other physicians have prescribed. This can lead to drug interactions that diminish the effectiveness of the medications and can result in serious side effects.
5. A simplistic belief that psychiatric illnesses represent "chemical imbalances" - Many patients and doctors believe that psychiatric illnesses result from imbalances in brain chemistry. Psychiatric disorders likely reflect complex dysfunction in brain networks that underlie cognition, emotions, and motivation. These networks use neurotransmitters (chemicals) to send and receive information. While manipulating some of these chemicals (for example, serotonin or dopamine) can produce clinical benefits, we don't yet understand what is wrong with brain networks in psychiatric disorders and how the medications affect network function. The point here is that if one buys into the "chemical imbalance" myth, then it might make sense to juggle multiple medications in order to "rebalance" the system. However, human behavior and the breakdown of human behavior involve complex interactions of the brain and the environment. Simple fixes do not occur by the simultaneous use of multiple psychiatric medications. What is certain is that the probability of significant side effects increases with the use of more medications.
These are just a few of the reasons why patients end up taking a large number of medications. There are likely to be numerous others.
What can be done? It is important for patients to let each of their doctors know about all of the medications they are taking - both prescribed medications and over-the-counter medications. Similarly, it is important for physicians to know about all alcohol, nicotine, caffeine, and illicit drug use. It is also important for patients to be honest about whether they are taking their medications as prescribed. Failure of patients to follow through with recommendations can contribute to doctors prescribing additional medications inappropriately. Patients should initiate discussions with prescribing doctors about the purpose of each medication and, if a person is on a large number of medications, discuss whether gradual simplification of the regimen may be possible. If so, the doctor will often recommend that changes be made very gradually.
Patients should discuss with their doctors how soon they might expect to see improvement in their symptoms. It is important to understand that the beneficial effects of most psychotropic medications take time. Though it is understandable that patients want immediate relief from their symptoms, physicians may try to accommodate demanding patients by adding more medications or rapidly escalating the doses of medications. Often this will lead to more side effects, more costs, and probably no increased benefit.
It is worth repeating that the appropriate use of one or a few medications for an accurately diagnosed illness can be life-saving. Our point here is to differentiate the appropriate use of powerful medications from the unfortunately common practice of irrational polypharmacy. We would also add that our comments about polypharmacy are not unique to psychiatry and generalize to other fields of medicine. For example, treatment of many common chronic illnesses such as hypertension and epilepsy can also be associated with irrational polypharmacy.
This post was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD. Neither has any financial conflicts of interest involving the pharmaceutical industry.