Polypharmacy in psychiatry: a multi-state comparison of psychotropic drug combinations.

Surveys of prescription practices have indicated that what was initially a novel treatment choice begins to be employed with greater frequency in psychiatric samples. While data from geriatric samples show an apparent restraint on the part of psychiatrists in use of potent neuroleptic combinations, it is clear, drug combinations are still employed in older patients. Combinations of specific psychotropic agents are related to sex and age of the patient with the most frequent combination of drug type being of neuroleptic and antidepressant. This study presents data derived from an incidental sample of psychiatrists from four states having large patient and psychiatrist populations. A single case questionnaire survey was devoted to identifying the types of drugs used in combination. It was clear that this sample of psychiatrists, from diverse backgrounds who are responding to the same set of symptoms, used a broad array of drug combinations. Chlorpromazine-trifluoperazine was the combination showing most frequent use. As the patients' symptoms persisted, combinations of drugs used in treatment became more unique and diverse. After one year of ineffective chemotherapy combinations of three and up to six potent neuroleptics were prescribed. It would seem that once drugs were prescribed in combination then it becomes easier to add another and another to a failing chemotherapeutic regimen. New York respondents combined two drugs most frequently. Some go to combinations of three, four, and as many as six drugs at one time. Pennsylvania psychiatrists were next most frequent in multiple drug use. California and Texas respondents used combinations least frequently. Nonetheless, concern regarding polypharmacy practices may need to give way to "maxipharmacy" which in the extreme was represented by a regimen of six neuroleptic agents which included: fluphenazine-haloperidol-promazine-thioridazine-thiothixene-trifluoperazine. The proliferation of potent but partially effective psychotropic drugs has advanced the development of unnecessary treatment procedures. Polypharmacy in psychiatry represents an example of a "legitimate" but unnecessary use of psychotropic agents. The use of combinations of psychoactive medications developed and continues largely out of arbitrary clinical experience instead of evolving from medical data. Use of polypharmacy in treatment is similar in kind to developing a new generation of treatment forms, essentially investigational with insufficient evidence available regarding compatibility, dose response factors, side effects and relative efficacy.