Monday, September 27, 2010

Polypharmically Incorrect

I continue to be amazed by the bizzaro combination drug cocktails that have been prescribed to patients coming to see me for the first time, either in my private practice or in the residents' clinic, who had previously seen another psychiatrist.  These chemical stews make no sense pharmacologically, let alone diagnostically.  To paraphrase an old song, "Uppers in the morning, downers in the evening, sugar at suppertime..." 

I'm not just talking about an occasional patient, by the way.  I'm talking about a big percentage here.

I have been having some interesting conversations with people who, after being harmed by inappropriate psychiatric medications, go on the warpath.  They start websites that bash psychiatric drugs in general (;  They talk to a lot of other people who claim to have had horrible experiences with psychiatric drugs, which no doubt many of them have.

The website webmasters tend to think that all psych drugs are evil in all cases, and I can't say that I blame them, although clearly I do not agree with them.  However, my guess is that they are talking to a biased sample of people.

Some of the people they talk to are the people who have had a bad reaction to one specific drug, a certain number of which would be expected with any medication (one can indeed bleed to death after taking an aspirin), or a bad withdrawal reaction.

Others had been victimized by psychiatrists who did not appropriately follow their patients for side effects and then take the patient off the medication if necessary.  This sort of thing happens all the time in the case of "atypical" antipsychotics, which can cause huge weight gain, cholesterol problems and diabetes. 

Still others are probably those who have been inappropriately diagnosed with bogus disorders such as "bipolar II" and "adult ADHD" and actually have personality problems, or who are misdiagnosed dysthymics who need therapy and not just medication.  And the vast majority of the people diagnosed with the bogus disorders generally do not even met DSM diagnostic criteria for the bogus disorders!

Most importantly, a high percentage of these people probably have been placed on the aforementioned bizarre drug combinations. Often the patients I see had been prescribed several different drugs from the same class at the same time, or drugs that have opposite effects on the brain.  Many are patients with mild symptoms that probably would not have responded to medications anyway, yet are put on more medications precisely because they did not respond.

Now I hear tell of a study that seems to validate my perceptions of what is going on in the field.  Truely objective psychiatric dissidents like Dan Carlat have been called anti-psychiatry for pointing out stuff like this, but it is the psychiatrists who are practicing bad psychiatry who are giving psychiatrists a black eye, not the critics (and I like to consider myself as one of the dissidents).

A study of antidepressant and antipsychotic treatment effects showed there is an emphasis on "polypharmacy" in clinical practice, without much evidence of benefit and an increase in adverse effects. Swiss investigators reported these findings at the 23rd European College of Neuropsychopharmacology Congress (23rd European College of Neuropsychopharmacology (ECNP) Congress: Abstract P.2.c.019. Presented August 31, 2010).

"In our study, we found no advantages for 'complex' treatment approaches over conventional monotherapeutic approaches," said senior investigator Hans H. Stassen, PhD, of University Hospital of Psychiatry in Zurich, Switzerland. "There appear to be no controlled studies showing the superiority of combinations of drugs over [a single drug (monotherapy)]. We looked at this because we have observed in clinical practice that response rates are less and side effects are greater." (reported by Medscape).

Treatment with antidepressants and antipsychotics was often non-specific in a number of ways, according to the study authors. Yet polypharmaceutical approaches have gained favor in recent years. Today' treatment regimens rely on various combinations of antidepressants, antipsychotics, mood stabilizers, anxiolytics, hypnotics, analgesics, and antiparkinson drugs.

Aggressive treatment of "mild" cases has rarely been shown to be superior to placebo, the investigators noted. This may explain why response rates have continuously decreased in recent years, whereas the proportion of incomplete responders has increased.

After two weeks in the study,  26% of patients followed were treated with a combination of 2 or more antidepressants, and 32.6% with a combination of antidepressants and antipsychotics. During the observation period of 6 weeks, the polypharmacy patients received an average of 8.3 different drugs, with a maximum number of 20.  Twenty!!!

"The observed polypharmaceutical treatment patterns appeared to be primarily associated with the psychiatrist in charge and much less with the patients' severity at baseline," an investigator noted.

In a comparison of monotherapy, polypharmaceutic treatment regimens, and placebo mean change in Hamilton Depression score (a symptom checklist) among patients matched for severity at baseline was −16 (higher minus numbers mean fewer and less severe symptoms) with monotherapy and −8 with both the combination approach and placebo.

In addition, during the 6-week study, the percentage of patients with cardiovascular problems increased from 8.8% to 30.7%.


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