Polypharmacy — Sloppy thinking in psychiatry 2

My second post in this series on sloppy thinking in psychiatry is devoted to polypharmacy, the medical term for prescribing multiple medications at once, especially for the same problem.  Polypharmacy is at best a risk thoughtfully taken because nothing simpler and safer will do.  At worst it’s a dangerous error, exposing patients to unnecessary hazards purely as a result of laziness and sloppy thinking by their doctors.  Unfortunately, the latter is all too common in psychiatry.  Let’s look at why.

It has been said that the less we know about an illness, the more treatments we have for it.  Instead of one definitive cure that attacks the root of the problem, various remedies ease symptoms — not the cause — often via different mechanisms.  A good example of a definitive cure is a specific antibiotic to treat a bladder infection.  We know how bacterial infections work, and we have antibiotics to attack the root of the problem.  Ancillary treatments for fever or pain are sometimes used, but they are clearly secondary, and often optional.  In contrast, the pathogenesis of psychiatric disorders is not known, thus we have no treatments to attack the roots of these problems.  For example, antidepressants affect neurotransmitters that appear implicated in depression, but the exact way these neurotransmitters relate to the syndrome of depression is unknown.  Thanks to our ignorance, we have medications that affect serotonin, and others that affect norepinephrine and/or dopamine.  In recent years atypical neuroleptics (antipsychotics) have been approved as add-ons for treating depression, a worrisome development given their risks.

Since we don’t have a definitive cure for depression, many patients report partial (or minimal) improvement from any one medication.  The prescriber may then add another on the theory that it may help via a different chemical mechanism — a theory that is difficult to confirm or refute, as we don’t know the mechanism in the first place.  The original medication is not stopped: If the patient improves, why disrupt a winning combination?  And if the patient doesn’t improve, we wouldn’t want to withhold an antidepressant from a depressed person, would we?  Sloppy thinking all around, yet sadly common.

Similar arguments can be made for the treatment of bipolar disorder and schizophrenia.  Lacking a true understanding of pathogenesis, we treat empirically.  And empiric treatment, while often compassionate and necessary and helpful, invites the shaky logic of adding more medications hoping for more empiric benefit.

Compounding and worsening this situation is psychiatry’s abandonment of parsimony in diagnosis and clinical assessment over the past 30 years.  Prior to the publication of DSM-III in 1980, psychiatric evaluation was an attempt to explain a patient’s seemingly unrelated complaints using a single theory (often psychoanalytic, but possibly biological or even behavioral).  The introduction of phenomenological diagnosis in DSM-III encouraged multiple diagnoses in the same patient, say Major Depression and PTSD on Axis I, and a personality disorder on Axis II.  There was no longer any attempt to tie it all together.  This has encouraged a piecemeal approach to treatment: a medication for depression, a different one for PTSD, maybe something for sleep, and something else again for agitation due to the personality disorder.  That’s four different psychiatric medications already, and we’ve hardly even started.  Patients with personality disorders often complain of “mood swings,” so let’s add a mood stabilizer like lithium or Depakote.  And they’re anxious, so we could add a benzodiazepine tranquilizer like Ativan, or a beta-blocker like propranolol, or an atypical neuroleptic.  Or what the hell, all three!  We’re up to seven or eight medications now, and we haven’t even considered a stimulant for their ADHD — because, after all, the patient is having trouble concentrating… funny how it was never diagnosed before.  And we haven’t augmented the antidepressant with thyroid supplementation, nor have we added a second antidepressant…

While 10+ psychiatric medications is clearly over top, I’ve evaluated a number of patients who arrive on six, often an (1) antidepressant, (2) mood stabilizer, (3) tranquilizer, (4) sleep aid, (5) stimulant, and (6) another antidepressant or mood stabilizer.  Almost without exception, I’ve been able to cut this list in half, and in some cases down to zero, or more often, one medication.  It’s less a matter of expert medication choice, and more an aversion to sloppy thinking.  According to one study, antipsychotic polypharmacy can be simplified without harm 2/3 of the time.

Psychiatric polypharmacy is often intellectually lazy.  Needless to say, there are far more drug combinations than there are studies assessing the risks and benefits of these combinations.  Polypharmacy is nearly always an educated guess, not “evidence based medicine.”  It’s not even good single-case research, where one would ideally change a single variable at a time.  All too often, medications are added to treat the side-effects of other medications, as with “ADHD” in the case above, a tail-chasing exercise that only gets worse over time.  With every added medication there are added side-effects, and sometimes adverse interactions that can be more harmful than the original problem.  In my experience, generic side-effects such as weight gain and cloudy thinking are more the rule than the exception in patients taking multiple psychiatric medications.  It should happen a lot less than it does.

Once again, photo courtesy of Petr Kratochvil.

11 comments to Polypharmacy — Sloppy thinking in psychiatry 2

  • […] try it,” this doesn’t bode well for the future of our field.  This strategy is mindless and sloppy, not to mention potentially dangerous.  It opens the floodgates for expensive and relatively […]

  • Stop.Psychiatry

    Dr Reidbord, I come here from Dr Balt’s blog. He/you have a very good understanding of the way psychiatry is “malpracticed”, yet you continue to defend it. If we agree that these psychiatric medications do things, such as altering the serotonin levels in the brain, that we don’t know exactly how/if they are related to the disorder they pretend to treat (depression or, as it was my case, OCD), why should that be a treatment approved in the first place? Wouldn’t it be more honest to ban the use of these drugs or at least limit them to the very extreme cases, certainly more extreme than the 10% of Americans that allegedly take SSRIs now? I repeat, and I like your bladder infection analogy, that the way psychiatry deals with mental issues would be considered scientific misconduct in every respected field of science. PS: the email address provided is real.

    • I like to believe I defend the good parts of psychiatry, while criticizing the bad parts. In my view, the field is not all bad by a long shot. If you sign yourself “Stop.Psychiatry” I guess we’ll have to disagree on that.

      A medication is approved by the FDA if it is shown in systematic group studies to be safe and effective for its intended use. There is no requirement that anyone knows HOW its works. Of course, some people disagree with the FDA’s decisions, or with the data used to make those decisions. But all currently available psychiatric medications have been approved in this way. Once approved, doctors are allowed to prescribe these drugs for mild cases, severe cases, and even “off label” for conditions that have nothing to do with FDA approval.

      For example, Abilify is an FDA-approved antipsychotic. It effectively decreases psychotic symptoms, and given the hazards and distress of psychosis, it does so with acceptable levels of medical risk. I have no objection to using Abilify in this way, except that it’s very expensive. However, I do object to using (or more precisely, to widely marketing) Abilify for non-psychotic depression, which is another FDA-approved use, as the medical risks seem excessive for this application. And I very much object to using it as a sleeping pill, a common “off label” use, since there are far safer and cheaper alternatives.

      Getting doctors to use medications wisely isn’t a matter of banning these treatments outright, since they do help some patients. Moreover, current laws don’t make it easy to limit which cases a doctor is allowed to treat. We’re left with good professional education, peer pressure from other doctors, and public outcry to change prescribing practices.

      Most “respected fields of science” understand the underlying mechanisms in their field. Chemists can explain why a particular chemical reaction happens, and astronomers can account for the motion of heavenly bodies with great accuracy. But when a field is young, it is mainly observational and descriptive. In the 1800s many chemicals were categorized by their taste, not by how they reacted. And for centuries astronomers did not know the physics behind their observations. Psychology and psychiatry are still young fields, still mainly observational and descriptive. In my view, this should make us humble, but it is not an argument for giving up. Thanks for writing.

      • Stop.Psychiatry submitted a 1200 word reply, which I won’t be printing here. Concise comments on post topics, in this case psychiatric polypharmacy, are welcome. Multi-page antipsychiatric diatribes are not. You’ll need to create your own blog in order to have the editorial freedom to go on for as long as you like. Here on mine, we disagree on whether psychiatry is evil, utterly corrupt, and so forth, and will have to leave it at that. — S.R.

        • Stop.Psychiatry

          I am not sure if you’ll publish this, however I find it very disturbing that you censored my response that was fact based and included links to publicly available information. Your reaction is the very reason I keep my identity confidential. I guess that it must not be easy to digest that you are one of the many mercenaries of human misery and that, as long as you get paid, you couldn’t care less about the misery your discipline causes in society. All the best.

        • I’m not surprised you find it disturbing; you feel entitled to a soapbox even when it rudely insults your host. Imagine you wrote a blog about your collection of, say, 1960s sports cars, and an anonymous critic of fossil fuels wrote a 4-page putdown of everyone who drives cars, complete with overstated data and overgeneralized conclusions. I’m not so sure you’d publish it, nor would you be so quick to call it censorship if you didn’t. Feel free to criticize psychiatry in general… just not on my blog. As for being a “mercenary of human misery” and “you couldn’t care less,” you obviously don’t know me, and haven’t even bothered to read other posts on this blog. You merely need a target for your rage, and I decline to stand in the bullseye. My first reply to you was respectful, you didn’t treat me in kind. All the best to you too.

  • Anonymous

    That was an interesting post and kind of relevant to what I am going through right now. I really don’t know what to do. I have ADHD, but stimulants are hard on my body. I get some really bad panic attacks and rebound issues. I tried Strattera, but the side effects were so bad that I couldn’t even make it through the first week. Stimulants are very effective, but if I were going to take stims then that would involve some polypharmacy…however, I’m a terrible patient to medicate. Put me on an SSRI and I will start getting rage issues and get really moody. Give me blood pressure meds and as soon as they wear off the panic attacks triggered by the stimulant will just start up all over again. Put me on a long acting blood pressure med. and I’m dead tired with muscle weakness. Polypharm is not my friend. I asked my psychiatrist about just trying straight up guanfacine, but he said he doesn’t think it actually improves focus. He thinks it just calms down hyperactive kids and isn’t worth a try.

    They really need to invent more nonstimulant meds for ADHD. Don’t remember why I gave up on Wellbutrin years ago. Guess it wasn’t that effective. I’m going to try Ginseng and see if that helps at all. I never made an attempt at alternative medicine. I think ADHD is usually a lot easier to medicate, but my brain is just weird.

    • Many non-medication treatments for ADHD have been proposed, from modified diets to supplements to behavioral therapies. I don’t know the evidence base for any of these — ADHD isn’t something I treat much at all — but you might look into them. Thanks for writing.

  • I really don’t understand why psychiatry doesn’t understand a very basic medical principle: Increasing the number of medications increases iatrogenic complications.

    It used to be that good medicine meant medications very sparingly — see http://archinte.jamanetwork.com/article.aspx?doi=10.1001/archinternmed.2011.256.

    On top of the unrecognized adverse effects and drug-drug interactions in psychiatric polypharmacy, the drug burden can interfere with medically necessary medications.

    Many people are unnecessarily put on psychiatric drugs for years. As they age, they may develop real medical conditions such as cardiac, blood pressure, or blood sugar problems (the risk for all of these are raised by psychiatric drugs).

    Those truly life-threatening conditions do sometimes call for multiple medications. You have someone on a pre-existing regimen of 2, 3, or 4 psychiatric drugs, then add some more for the real medical conditions — polypharmacy compounded.

    It’s as though each specialty claims primacy in the patient’s body for its own drugs, regardless of the overall risk-benefit to the patient’s health.

    And psychiatry is in there claiming its own cocktail deserves prime real estate, even though its benefits are questionable!

    Since when did this kind of expansionism become acceptable in medicine?

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