Combination pharmacotherapy for schizophrenia is reportedly increasingly common in the community ( 1 ). Yet efficacy of medication combinations for the treatment of schizophrenia and the frequency of such practices in different treatment settings remain largely unstudied. In addition, second-generation antipsychotics in combination pose an increased side-effect and risk burden at significant public and private cost.
In order to determine patterns of prescribed second-generation antipsychotic combinations, we calculated frequencies using administrative and prescription data for over 6,000 individuals served by a large public mental health system for one month in 2002. Individuals were over the age of 18 and had a schizophrenia spectrum disorder.
Seventy-six percent of individuals in the study (5,083 of 6,666 individuals) were given prescriptions for at least one second-generation antipsychotic medication. As shown in Figure 1, of the individuals who received a second-generation antipsychotic, many also received at least one other medication.
Figure 1 Medications given in combination with a second-generation antipsychotic
Our study demonstrates how analysis of a large administrative database can improve knowledge of real-world psychopharmacological practices and enhance treatment improvement efforts. Despite the reported milder side-effect profile of second-generation antipsychotics, many patients received anticholinergic medications. This may reflect higher total dosages of antipsychotic medications, multiple antipsychotic medications, or overuse of anticholinergic medication ( 2 ). Other than for a brief period while a drug is being tapered, antipsychotic polypharmacy is inconsistent with current treatment guidelines, unsupported by rigorous research, and costly.
This administrative database did not allow verification of diagnoses with standardized instruments, and limited information about dosages and duration did not allow us to determine total dosage or whether polypharmacy was short or long term.
Subsequent steps should include further research to explore efficacy and risks of medication combinations for treatment of schizophrenia and other alternative strategies to polypharmacy.
Acknowledgments and disclosures
Dr. Eisen and Dr. Wells were co-principal investigators on a study funded by Eli Lilly and Company. The other authors report no competing interests.
Footnote
Dr. Eisen is affiliated with the Department of Mental Health, Los Angeles County, and with the Semel Institute for Neuroscience and Human Behavior, Health Services Research Center, University of California, Los Angeles (UCLA), 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024 (e-mail: croeloff@ucla. edu). Dr. Shaner is the medical director of Los Angeles County Department of Mental Health. Dr. Unützer is with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Dr. Fink is with the Department of Medicine, UCLA. Dr. Wells is affiliated with the Semel Institute for Neuroscience and Human Behavior, Health Services Research Center, UCLA, and with RAND Corporation, Santa Monica. Harold Alan Pincus, M.D., and Amy M. Kilbourne, Ph.D., M.P.H., served as editors of this column.
References
1.
Tapp A, Wood AE, Secrest L, et al: Combination antipsychotic therapy in clinical practice. Psychiatric Services 54:55–59, 2003
Ascher-Svanum H, Kennedy JS, Lee S, et al: The rate, pattern and cost of use of antiparkinsonian agents among patients treated for schizophrenia in a managed care setting. American Journal of Managed Care 10:20–24, 2004
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