Focus on Evidence

Thank you for reporting on the results of a survey concerning the California Medicaid program in the March 17 article “Antipsychotic Polypharmacy: Value for Money?” The survey found that antipsychotic polypharmacy costs three times as much as monotherapy.

The scope of the polypharmacy problem is widespread especially in state psychiatric facilities. Even though cost is an important aspect of management in this era of managed care, experience has shown that doctors are usually defensive about their prescribing practices when the challenge is based on cost.

Considering that a significant number of patients in state psychiatric facilities may be treatment resistant, global condemnation of antipsychotic combination may be misdirected. While regular audit and individual comparison with anonymous peers is critical to monitor practices as compared with existing standards, it must be coupled with regular educational programs.

Unlike the broad-based programs that were found to be ineffective by some of the hospitals featured in the article, however, effective educational programs must be specifically focused on evidence-based prescribing practices. Such programs must also include evidence-based practical algorithms in cases in which rational combination is justified. For example, augmentation might be necessary under these conditions: when a patient fails to respond to adequate antipsychotic trials, especially with clozapine; in some instances of failed cross-taper of antipsychotics; and the addition of a first-generation antipsychotic to a second-generation antipsychotic when a patient is experiencing agitation during acute treatment of psychosis.