'Less is more' in the Chinese context.

Excessive polypharmacy is a common problem around the world, particularly in the treatment of psychiatric disorders. In mainland China use of out-of-date treatment strategies by psychiatric professionals is one of the reasons; others include unrealistically high expectations about the effectiveness of medications, the dominant role of the doctor in doctor-patient negotiations about treatment, the practice of polypharmacy in Traditional Chinese Medicine (TCM), the profit-driven nature of medical institutions and individuals, the infiltration of pharmaceutical marketing, and a critical lack of relevant research. This commentary considers the cultural factors that need to be addressed when trying to reduce polypharmacy in psychiatry in China.

Polypharmacy is a prominent phenomenon in global medical practice that is particularly problematic in psychiatric practice.[1, 2] Polypharmacy increases the prevalence and severity of adverse drug reactions and the cost of treatment. According to Healthy People 2020, polypharmacy among American elderly is the most important factor affecting the safety of pharmacological treatments in the elderly.[3]

Polypharmacy has multiple definitions, including (a) the simultaneous use of excessive medication; (b) the improper use of multiple medications; (c) the use of abnormal combinations of medications; and (d) having to use medications to treat the adverse reactions of other medications.[4] Apart from psychiatrists’ inadequate understanding of pharmacokinetics and pharmacodynamics of commonly used psychiatric medications, other factors that influence polypharmacy in psychiatric practice in mainland China include:

1) Unrealistic expectations about the effectiveness and rapidity of effect of psychiatric medications. Chinese patients generally believe in the effectiveness of medication, intravenous treatment, and other intrusive medical procedures - an approach that is reflected in the extremely high usage of antibiotics. However, patients and their family members in China are often unwilling to wait for the gradual improvements afforded by most medications used in psychiatry, particularly if the treating psychiatrist has not prepared them for the slow onset of treatment effects.[5] Clinicians’ desire to meet these unrealistic expectations of their patients often induces psychiatrists to resort to polypharmacy in an often unsuccessful attempt to speed-up the onset of clinical improvement.

2) Psychiatrists’ dominant position in the doctor-patient negotiations about treatment. The lack of knowledge of patients and their family members about psychiatric medications leaves the psychiatrist in control of the negotiations about treatment, particularly when discussing the simultaneous use of multiple psychiatric medications. Many mental illnesses are chronic, requiring ongoing pharmacological treatment and frequent interaction with mental health professionals. The use of polypharmacy can be an unintended (or intended) method of increasing the power of the psychiatrist in the long-lasting relationship between the psychiatrist and his or her patients.

3) Frequent use of multiple-component prescriptions in Traditional Chinese Medicine (TCM). Use of a single medication is uncommon in traditional Chinese medical practice. Following the TCM prescribing principles of ‘Monarch’, ‘Minister’, ‘Assistant’, and ‘Guide’ ( 君臣佐使), a TCM prescription is typically composed of at least four different kinds of medicinal materials.[6] Despite the lack of empirical evidence of effectiveness, [7] there is wide cultural acceptance of the use of compound preparations in medical practice among both clinicians and their patients. Approximately ten percent of the 20, 000 psychiatrists working in mainland China were trained in TCM medical schools and the remaining ninety percent received training in TCM as part of their training in Western medicine medical schools. This training normalizes polypharmacy in the use of TCM medications, a practice that often influences their use of western psychiatric medications.

4) The profit-driven nature of institutions and individuals. Although there are some psychiatrists working in first-class tertiary-level hospitals in large cities earning good salaries, overall remuneration for Chinese psychiatrists is relatively low both when compared to other medical professionals in China and particularly when compared with the reimbursement of physicians in high-income countries. In this setting, commercial bribery by under-regulated pharmaceutical companies (which pay psychiatrists unofficial ‘red packets’ for prescribing their medications) remains a widespread problem.[8] Moreover, the official bonuses of psychiatrists (like that of most other physicians in China) is often linked to the profit on the ward or clinic where they work, which is heavily influenced by the volume of medications prescribed. The more drugs prescribed the higher the legal and illegal bonuses, so it is not surprising that there is a tendency to promote polypharmacy. Restrictions on government-run hospitals (the vast majority of psychiatric hospitals are state-owned) on the permissible size of the mark-up (over cost) of medications is 15% while that of other types of services is only 10%, [9, 10] so there is little incentive for hospitals to reduce the common practice of polypharmacy of their physicians.

5) Professionals’ doubts about clinical guidelines for the use of medications. A considerable proportion of the two million Chinese doctors only have 3 years of college education (or less). They usually do not receive or understand the latest literature published in English or other non-Chinese languages. Moreover, most continuing medical education (CME) courses are run or funded by pharmaceutical companies because professional societies and governmental departments do not have the funds needed to provide ongoing postgraduate training to update the skills of physicians. When doctors walk into experts’ training sessions in conference venues filled with logos, hanging banners, product descriptions, free food, and other gifts, it is quite likely that they will not be attentive to the content of the speakers’ talks. Another problem is that given the relative lack of China-specific evidence-based research on psychiatric medications, several clinical guidelines and manuals are filled with translated content from western materials (often adapted without permission) that may or may not be appropriate in the Chinese setting. This problem is most acute in psychiatry because of its relatively slow development compared to that of other medical specialties in China. It is not particularly surprising that most Chinese clinicians disregard the recommendations of widely promulgated clinical guidelines (which typically recommend against polypharmacy).

In summary, addressing the serious issue of polypharmacy in psychiatry in China requires more than theoretical discussions of the psychopharmacological effects of the combined use of multiple drugs. There needs to be high-quality clinical research in China about these common combination treatments and the results of this research need to be converted into policies that will limit the use of polypharmacy regimens that are not proven to be more effective or safer than monotherapy.