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Psychiatry Newsletter - The Well-used Prescription Pad - a Hazard?

Hopkins BrainWise Fall 2010

The Well-used Prescription Pad - a Hazard?

Date: November 29, 2010

Dr. Ramin Mojtabai
“I think twice about adding a new medication. I think more about what I can do to maximize one I already have on board,” says Ramin Mojtabai, who’s with both Hopkins Psychiatry and Public Health.

Prescribing more than one medication for psychiatric illness can be as valuable as shooting steamed milk into espresso: The whole comes out significantly better than the parts. So, for example, using the second antidepressant buproprion to boost the “almost there” effect of citalopram can ease depression—it’s an approach that’s both tested in trials and anecdotally sound. The same holds for giving someone who’s depressed and hearing voices an antipsychotic agent along with an antidepressant.

But what about taking several antipsychotics for schizophrenia? Prescribing another antidepressant for someone chronically depressed and already on one SSRI and valium? “It’s the mixing of psychoactive drugs without a basis in good clinical trials that worries a lot of us,” says psychiatrist Ramin Mojtabai, “and it appears to be a trend.”

Recently Mojtabai reported a large-scale study of psychiatrists’ prescribing patterns. He and a colleague reviewed data from 1996 to 2006 on more than 13,000 visits to mostly private psychiatrists, as gathered in a national medical care survey.  The study is the largest of its kind.  And it shows, he says, that “we’re combining psychotropic medicines more while our knowledge of whether that’s a good idea hasn’t kept pace.” 

The number of patient visits in which psychotropic drugs were prescribed, for example, increased about 13 percent. And visits in which two or more medications were prescribed increased roughly 17 percent.

“I don’t want to discourage polypharmacy—having combinations—when it’s needed,” Mojtabai emphasizes. “But when it isn’t evidence-based, we can’t predict what side effects to anticipate as drugs interact,” he says, “nor are we sure enough of the benefits, especially when the added drugs are costly.” Also, he says, the more complex the drug regimen, “the more missed doses and noncompliance you see.”

What underlies the upswing? “It might be that the newer antidepressants and antipsychotics lack the florid side effects of earlier ones,” says Mojtabai, “and that makes combining drugs seem low risk.” SSRI antidepressants, for example, are especially perceived as benign, he adds. Also, more new drugs are on the market, and physicians may be sold on promises of added benefits. This spills over to patient demands. “One of my patients with bipolar disorder recently asked me for ‘the butterfly medication’ for his insomnia.”

But most polypharmacy, Mojtabai believes, comes out of the not-uncommon situation when one medication is only partially successful and there’s no guideline for what should happen next. “Say a patient improves on the first drug, but responds even better to a second. Should you taper off the first one? Sometimes you do that and the patient declines, so you have them stay on the first. And that’s how accumulation can start.”

How to remedy? “We need clinical trials on combinations!” he says. “And the FDA should instigate them, since those aren’t likely to be industry-sponsored.” Also, even something as simple as prompting greater use of online medical records would tell what’s helped a forgetful patient in the past and lessen the likelihood of additions.

But perhaps more primal change is needed: Mojtabai cites studies that show a dip in U.S. psychiatrists’ use of psychotherapy. Because today’s view of mental disorders and treatments emphasize biology, he says, “that supports medications in general and may indirectly foster polypharmacy.” A greater openness to add tested behavioral approaches, he says, might be in order.