Polypharmacy Subtypes In Psychiatry: The rational, the reasonable, the ridiculous & the hazardous

There has been an increasing trend towards polypharmacy (concomitant use of five or more medicines), over the last few decades. Considering the complex presentation and high prevalence of multimorbidity, the prevalence of polypharmacy in psychiatric illnesses is not surprising. Polypharmacy for psychotropics is defined as the concomitant use of two or more psychotropics but there is no consensus about this. Polypharmacy can be based on the number of active components per patient or/& the classic numerical approach (prescriptions per patient). Around one third of the patients with serious illnesses like schizophrenia and bipolar disorder, receive complex polypharmacy. A high prevalence of comorbidity, uncertainty about the aetiology or patho-physiology of disorder, limited pharmacological targets, restricted efficiency of some drugs, non-availability of evidence-based psychopharmacological guidelines and differences in response are important contributing factors. Polypharmacy, though indicated and rational in some cases, it is established as a health risk and is associated with increased mortality. Patients taking multiple medicines are at risk of drug–drug interactions or side effects. It causes potentially inappropriate prescribing such as contra-indicated medicines, under or overdosing of medicines, combining medicines with opposite pharmacodynamics, etc. Further, there are chances of poor adherence due to a complex medicine schedule. In general, polypharmacy reflects the practitioners’ desperation in managing severely ill, treatment-resistant patients, usually in absence of evidence-based guidelines. Nasrallah HA (2011) categorized polypharmacy into 4 subtypes that span the spectrum from sensible to absurd. 1) Rational/Necessary polypharmacy (evidence-based and proven to be more effective than monotherapy) 2) Reasonable polypharmacy (not FDA-approved, but supportive evidence of usefulness is present.) 3) Ridiculous polypharmacy (absurd combination of psychotropic drugs across several classes) 4) Hazardous polypharmacy (serious medical complications, toxic effects or death may occur because of careless combinations of drugs). In this symposium authors will discuss about how polypharmacy can relieve the anguish of psychosis, depression or anxiety, along with the iatrogenic risks, if not based on scientific evidence as the practice of psychopharmacology requires the fully integrated skills of psychiatric training to maximize benefit and avoiding harm. Authors will also discuss the types of polypharmacy and the way it affects the clinical practice in psychiatry with respect to patient (course and prognosis) as well as psychiatrist. Authors will also point out to the possibility of specific guidelines formulation about the psychotropic polypharmacy.