How Psychotropic Polypharmacy in Schizophrenia Begins: A Longitudinal Perspective

M. Shinfuku; H. Uchida; C. Tsutsumi; T. Suzuki; K. Watanabe; Y. Kimura; Y. Tsutsumi; K. Ishii; Y. Imasaka; M. Mimura; S. Kapur

doi:10.1055/s-0031-1297934

Pharmacopsychiatry, Table of Contents

Pharmacopsychiatry 2012; 45(04): 133-137
DOI: 10.1055/s-0031-1297934

Original Paper

How Psychotropic Polypharmacy in Schizophrenia Begins: A Longitudinal Perspective

M. Shinfuku

¹Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

²Department of Psychiatry, Asaka Hospital, Fukushima, Japan

,

H. Uchida

¹Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

³Geriatric Mental Health Program, Centre for Addiction and Mental Health,Toronto, Canada

⁴Department of Psychiatry, Asakadai Mental Clinic, Saitama, Japan

,

C. Tsutsumi

¹Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

⁵Department of Psychiatry, Komagino Hospital,Tokyo, Japan

,

T. Suzuki

¹Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

,

K. Watanabe

¹Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

⁶Department of Psychiatry, Ohizumi Hospital, Tokyo, Japan

,

Y. Kimura

⁴Department of Psychiatry, Asakadai Mental Clinic, Saitama, Japan

⁶Department of Psychiatry, Ohizumi Hospital, Tokyo, Japan

,

Y. Tsutsumi

⁷Department of Psychiatry, Ongata Hospital, Tokyo, Japan

,

K. Ishii

⁶Department of Psychiatry, Ohizumi Hospital, Tokyo, Japan

,

Y. Imasaka

⁶Department of Psychiatry, Ohizumi Hospital, Tokyo, Japan

⁸Department of Psychiatry, Ohizumi Mental Clinic, Tokyo, Japan

,

M. Mimura

¹Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

,

S. Kapur

⁹Institute of Psychiatry, King’s College, London, United Kingdom

› Author Affiliations

Abstract

Introduction:

While patients with schizophrenia are often treated with psychotropic polypharmacy, how and when polypharmacy begins is not well documented.

Methods:

A systematic chart review of 300 patients, 100 of whom were psychotropic-free prior to their first visit, was conducted to examine 2-year longitudinal prescription patterns of concomitant psychotropics, in addition to a primary antipsychotic.

Results:

Overall polypharmacy occurred in 79% patients, with 2-year rates of the use of hypnotics, benzodiazepine derivative anxiolytics, anticholinergic drugs, antidepressants, and mood stabilizers were 56.7, 49.7, 38.3, 21.3, and 14.0%, respectively. Once polypharmacy had started, it was continued until their final visit in >70% of the patients. In a subgroup of 100 psychotropic-free patients, mood stabilizers, antidepressants, anticholinergic antiparkinsonian drugs, anxiolytics, and hypnotics were initiated after 2.3, 2.3, 2.1, 1.6, and 1.5 antipsychotics had been prescribed, respectively (mean duration before the introduction of a concomitant drug in days: 17.7, 121.6, 86.4, 32.1, and, 57.7, respectively).

Conclusion:

Routine practice deviates significantly from algorithms – with polypharmacy often being initiated early, often a without trial of other options, and once started commonly stays.

Key words

concomitant drugs - polypharmacy - psychotropics - schizophrenia

Full Text

References

References
1 Chakos MH, Glick ID, Miller AL et al. Baseline use of concomitant psychotropic medications to treat schizophrenia in the CATIE trial. Psychiatr Serv 2006; 57: 1094-1101
2 Magliano L, Fiorillo A, Guarneri M et al. Prescription of psychotropic drugs to patients with schizophrenia: an Italian national survey. Eur J Clin Pharmacol 2004; 60: 513-522
3 Fourrier A, Gasquet I, Allicar MP et al. Patterns of neuroleptic drug prescription: a national cross-sectional survey of a random sample of French psychiatrists. Br J Clin Pharmacol 2000; 49: 80-86
4 McCue RE, Waheed R, Urcuyo L. Polypharmacy in patients with schizophrenia. J Clin Psychiatry 2003; 64: 984-989
5 Acquaviva E, Gasquet I, Falissard B. Psychotropic combination in schizophrenia. Eur J Clin Pharmacol 2005; 61: 855-861
6 Mallinger JB, Lamberti SJ. Racial differences in the use of adjunctive psychotropic medications for patients with schizophrenia. J Ment Health Policy Econ 2007; 10: 15-22
7 Lehman AF, Lieberman JA, Dixon LB et al. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry 2004; 161: 1-56
8 Buchanan RW, Kreyenbuhl J, Kelly DL et al. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull 2010; 36: 71-93
9 Tsutsumi C, Uchida H, Suzuki T et al. The evolution of antipsychotic switch and polypharmacy in natural practice – A longitudinal perspective. Schizophr Res 2011; 130: 40-46
10 Vares M, Saetre P, Stralin P et al. Concomitant medication of psychoses in a lifetime perspective. Hum Psychopharmacol June 22 2011; [E-pub ahead of print]
11 World Health Organization . The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. World Health Organization; Geneva: 1992
12 Haahr U, Friis S, Larsen TK et al. First-episode psychosis: diagnostic stability over one and two years. Psychopathology 2008; 41: 322-329
13 Schwartz JE, Fennig S, Tanenberg-Karant M et al. Congruence of diagnoses 2 years after a first-admission diagnosis of psychosis. Arch Gen Psychiatry 2000; 57: 593-600
14 Gelenberg AJ, Van Putten T, Lavori PW et al. Anticholinergic effects on memory: benztropine versus amantadine. J Clin Psychopharmacol 1989; 9: 180-185
15 Mamo DC, Sweet RA, Keshavan MS. Managing antipsychotic-induced parkinsonism. Drug Saf 1999; 20: 269-275
16 Monane M, Avorn J, Beers MH et al. Anticholinergic drug use and bowel function in nursing home patients. Arch Intern Med 1993; 153: 633-638
17 Anonymous . Prophylactic use of anticholinergics in patients on long-term neuroleptic treatment. A consensus statement. World Health Organization heads of centres collaborating in WHO co-ordinated studies on biological aspects of mental illness. Br J Psychiatry 1990; 156: 412
18 Heinik J. Effects of trihexyphenidyl on MMSE and CAMCOG scores of medicated elderly patients with schizophrenia. Int Psychogeriatr 1998; 10: 103-108
19 Bottiggi KA, Salazar JC, Yu L et al. Long-term cognitive impact of anticholinergic medications in older adults. Am J Geriatr Psychiatry 2006; 14: 980-984
20 Kay GG, Abou-Donia MB, Messer Jr. WS et al. Antimuscarinic drugs for overactive bladder and their potential effects on cognitive function in older patients. J Am Geriatr Soc 2005; 53: 2195-2201
21 Uchida H, Mamo DC, Mulsant BH et al. Increased antipsychotic sensitivity in elderly patients: evidence and mechanisms. J Clin Psychiatry 2009; 70: 397-405
22 Singh MM, Kay SR. Therapeutic reversal with benxtropine in schizophrenics. Practical and theoretical significance. J Nerv Ment Dis 1975; 160: 258-266
23 Johnstone EC, Crow TJ, Ferrier IN et al. Adverse effects of anticholinergic medication on positive schizophrenic symptoms. Psychol Med 1983; 13: 513-527
24 Tonda ME, Guthrie SK. Treatment of acute neuroleptic-induced movement disorders. Pharmacotherapy 1994; 14: 543-560
25 Volz A, Khorsand V, Gillies D et al. Benzodiazepines for schizophrenia. Cochrane Database Syst Rev. 2007; CD006391
26 Swift CG, Swift MR, Hamley J et al. Side-effect ‘tolerance’ in elderly long-term recipients of benzodiazepine hypnotics. Age Ageing 1984; 13: 335-343
27 Angus WR, Romney DM. The effect of diazepam on patients’ memory. J Clin Psychopharmacol 1984; 4: 203-206
28 Nurmi-Luthje I, Kaukonen JP, Luthje P et al. Use of benzodiazepines and benzodiazepine-related drugs among 223 patients with an acute hip fracture in Finland: Comparison of benzodiazepine findings in medical records and laboratory assays. Drugs Aging 2006; 23: 27-37
29 Xiang YT, Weng YZ, Leung CM et al. Clinical and social determinants of long-term use of benzodiazepines and its impact on quality of life of Chinese schizophrenia patients. Pharmacopsychiatry 2007; 40: 269-274
30 Nutt DJ, Wilson S. Evaluation of severe insomnia in the general population – implications for the management of insomnia: the UK perspective. J Psychopharmacol 1999; 13: S33-S34
31 Moller HJ.. Effectiveness and safety of benzodiazepines. J Clin Psychopharmacol 1999; 19: 2S-11S
32 Nakajima S, Uchida H, Suzuki T et al. An open-label trial of discontinuing benzodiazepines in patients with chronic schizophrenia. J Clin Psychopharmacol 2007; 27: 401-403
33 Tsunoda K, Uchida H, Suzuki T et al. Effects of discontinuing benzodiazepine-derivative hypnotics on postural sway and cognitive functions in the elderly. Int J Geriatr Psychiatry 2010; 25: 1259-1265
34 Suzuki T, Uchida H, Takeuchi H et al. Augmentation of atypical antipsychotics with valproic acid. An open-label study for most difficult patients with schizophrenia. Human Psychopharmacol 2009; 24: 628-638
35 Uchida H, Suzuki T, Mamo DC et al. Effects of age and age of onset on prescribed antipsychotic dose in schizophrenia spectrum disorders: a survey of 1,418 patients in Japan. Am J Geriatr Psychiatry 2008; 16: 584-593
36 Uchida H, Suzuki T, Mamo DC et al. Benzodiazepine and antidepressant use in elderly patients with anxiety disorders: a survey of 796 outpatients in Japan. J Anxiety Disord 2009; 23: 477-481
37 Rummel C, Kissling W, Leucht S. Antidepressants for the negative symptoms of schizophrenia. Cochrane Database Syst Rev 2006; 3 CD005581