Understanding Polypharmacy in Psychiatry

Approximately 3 billion drugs are ordered or prescribed in the United States every year. The most commonly prescribed medications are pain medications and antidepressants. Although drugs are prescribed to many patients, not everyone responds the same. Different people respond differently towards the same medication. The process and challenges involved in treatment is a complex neuroscience. When multiple pharmaceutical drugs are prescribed at the same time to a single patient for an extended period of time, it is referred to as polypharmacy.  It is important to understand both the benefits and be aware of potential risks of polypharmacy. 

Different experts define ‘polypharmacy’ differently but the common definition for the word ‘polypharmacy’ is the concurrent use of multiple medications on a single patient.

There are several reasons why we use more than two medications in psychiatry. All FDA approved psychiatric medications won’t work the same for everyone and solve their medical issues. In our mind, we want just one pill to fix all our problems. Sadly, such pill does not exist. When individuals are prescribed any medication, there are four possible outcomes:

• Full positive response without side effects
• Full positive response with some side effects
• Partial response with or without side effects
• No response.

If an individual responds to a medication fully without any side effects, then the treatment is considered done. Unfortunately, this is not the case in most situations. If the response is any of the other three, using additional medications may be necessary.

The practice of using multiple medications is not unusual in psychiatry. Some psychiatric experts consider it acceptable to practice polypharmacy in an appropriate and rationale manner, referring to it as “rationale or appropriate polypharmacy”. On the other hand, the medical society is also extremely concerned with the growing practice of inappropriate or excessive or irrational use of medications.

Benefits

In rational polypharmacy, we end up using more than two medications in order to either maximize benefits, or minimize side effects.  In addition, you may have more than one psychiatric illness and therefore need more than one medication.

 Risks

Irrational or inappropriate polypharmacy can sometimes increase the risk of medication-related side effects through unexpected drug interactions. It also creates a complicated drug regime for you, making it difficult to take medications correctly. Because of this, the effects are sometimes indistinguishable from helping vs. harming, and the cost to you increases with each prescription.

Polypharmacy is most common in the elderly, affecting about 40% of older adults living in their own homes. Others at risk include psychiatric patients, patients taking five or more drugs concurrently, those with multiple physicians and pharmacies, and recently hospitalized patients.

Patients and family members of patients should play a more active role in taking responsibility of patient’s health and decision making. It is unfair to expect only one side either the medical providers or patients themselves to take full responsibility. Inappropriate polypharmacy can be avoided by educating patients and increasing awareness of illness. Here are some simple steps to help you prevent inappropriate polypharmacy:

• Know your family history and provide a comprehensive medical and family history to your doctor including a history of medication responses wherever possible.
• Use tools to monitor compliance, side effects and response towards medication.
• Ask questions, understand the rationale of a treatment and reasons behind why your physician is choosing a specific medication over another.
• Ask whether the prescribed medication is FDA approved or is it an off label medication?
• Involve a caregiver or family in the treatment process and coordinate care with all other treatment consultants.
• Have a personalized medical record.
• Have a realistic goal of expectations in the treatment process.