Editorial: The Dilemma of Polypharmacy in Psychiatry

The prevalence of polypharmacy in psychiatry varies between 13%-90%. The Polypharmacy can be categorized into four subtypes that span the spectrum from sensible to absurd. Polypharmacy subtypes are the necessary, the reasonable, the ridiculous, and the hazardous. The involvement of multiple neurotransmitter and receptor systems in illness may require multiple psychopharmacologic agents in order to selectively address each of them. The superiority of the SNR over the SSRI in several meta-analyses in unipolar depression validates this theoretical perspective that targeting two different neurotransmitter systems is better than targeting one neurotransmitter. In addition, the avoidance of side effects, to improve compliance and for slower tolerance, are other reasons for polypharmacy. Some 20% to 40% of patients with highly treatment-refractory illness presentations who show an excellent therapeutic response to a regimen involving one of the major mood stabilizers such as lithium, carbamazepine, or valproate will begin to experience a pattern of gradual loss of efficacy consistent with the development of pharmacodynamic tolerance. Combination treatment is associated with a slower development of tolerance than agents are with a single mechanism of action. Psychopharmacology can relieve the terrible anguish of psychosis, depression, or anxiety, but it also can carry iatrogenic risks if it is not based on scientific evidence. The practice of psychopharmacology requires the fully integrated skills of medical and psychiatric training to maximize benefit while avoiding harm. It requires basic arithmetic skills: to consider subtracting drugs, not only adding them. To some extent, polynosology and polypharmacy go together.