Combining Antipsychotics: Is more really better?
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.

1. Monotherapy (only one antipsychotic) is always best, if it works.

2. 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 domains.

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.