Combining Antipsychotics: Is more really
By Calvin Flowers, M.D.
It has become increasingly
common for patients with schizophrenia to be on more than one antipsychotic
medication concurrently. In fact, in most mental health systems approximately
1/3 of patients are taking two antipsychotics, and a small percentage are taking
more than two.
The critical question: Does this provide meaningful
differential effectiveness or are there hidden dangers associated with co
prescribing? The answer is, frustratingly, we don't know. However, there are
some overriding principles which can help guide this practice.
Monotherapy (only one antipsychotic) is always best, if it works.
Cross-tapering of antipsychotics, when moving from one agent to another, is an
appropriate time to co administer antipsychotics
3. Polytherapy (two
antipsychotics) may diminish potential gains in negative symptom
4. Use of two antipsychotics must have some theoretical basis
established by the prescribing clinician
5. Polytherapy should be
supported by documented improvements, i.e. if the patient does no better on two
agents than one, they should be on only one.
6. Consider higher does with
a single medication, before combing antipsychotics
7. Clozaril trials
should precede any combination strategies.
There is little research to
guide the clinician in antipsychotic polytherapy, however it remains a common
practice. Until this research is done, these guidelines will help.