Drs. Shim and Kelly Reply

To The Editor: We agree with Drs. Hazra, Mamo, and Remington that antipsychotic monotherapy is the standard of care for treating schizophrenia. Polypharmacy should only be considered as a last resort because of the potential for adverse effects and economic burden. When metabolic or extrapyramidal side effects or clinical consequences of hyperprolactinemia develop during antipsychotic treatment, strategies to eliminate or reduce these side effects should involve lowering the dose or switching to other agents.

For many chronic patients with multiple relapses, however, lowering the dose and switching treatments are not always effective and not always feasible in clinical practice. In our study, subjects with hyperprolactinemia, stabilized on high-dose haloperidol, were chronic with a history of multiple relapses. We recognize that some studies have demonstrated equivalent efficacy of aripiprazole and haloperidol in the treatment of schizophrenia symptoms (1) and that switching to aripiprazole from haloperidol has been found to be safe and effective (2) ; however, other studies have shown worsening of psychotic symptoms after switching to aripiprazole in some patients who were chronic and appeared only partially responsive to previous antipsychotics (3, 4) .

There is a growing need to consider new and different treatment strategies, whether they are adjunctive or monotherapeutic, for schizophrenia symptoms that continue to be resistant or only partially responsive to treatment. Recently, some studies have reported that the combination of aripiprazole with other antipsychotics improved refractory schizophrenia symptoms (5, 6) .

Our study was not intended to encourage or advocate the blanket use of antipsychotic polypharmacy, and unless empirical evidence suggests that there are beneficial effects of polypharmacy for schizophrenia, the smallest number of medications possible should be used to treat our patients with this illness. While we share the concerns expressed by Drs. Hazra, Mamo, and Remington, we also feel that clinicians should not underestimate the importance and significance of addressing and treating antipsychotic side effects such as the clinical consequences of hyperprolactinemia.