Polypharmacy versus Drug Combinations

Drug combinations have been known to be used either for increasing effcctivity or for decreasing side-efFects. It is only when multiple drugs are prescribed without adequate scientific evidence in their favour then such practices need careful scrutiny. Multiple drug use in psychiatry has recently gained currency and so require thoughtful consideration. The term polypharmacy is generally used to denote such practices. Combinations of neuroleptics, anticholinergics, antidepressants and anxiolytics have become widely prevalent. Interestingly enough, large number of practitioner' use combination of more than one neuroleptic or antidepressant for which there is hardly any justification. Such practices have led to the extensive manufacturing of drug combinations by a large number of pharmaceutical houses in this country. Since the situation does exist and before it takes a serious magnitude, it is imperative to consider the motivations for polypharmacy and Us benefits and ill-effects. Some of the main motives underlying the use of polypharmacy could be (a) psychological insecurity of the therapist in prescribing single drug lest the patient may feel dissatisfied with a short prescription; (b^ drug use is purely symptom-based; and (c) certain therapeutic situations rationally needing a drug combination. Commonest drug combination used in psychiatry is that of neuroleptics and anticholinergics. This practice appears to be so widespread that the Heads of WHO Centres of Biological Aspects of Mental Illness formulated a consensus statement that "the prophylactic use of anticholinergics in patients on neuroleptic treatment is not recommended, and may be justified only early in treatment (after which it should be discontinued and its need should be re-evaluated)." This statement has however, not met universal acceptance as many investigators feel that the withdrawal of anticho-linergic in some of the patients leads to re-emergence of extra pyramidal symptoms. Use of antidepressants in schizophrenia is another area which is riddled with controversies. Many authors feel that addition of antidepressants helps in relieving depression while most of the well-designed studies did not show any significant benefit by such combination. However, the role of anxiolytics in combinations with neurolep-tics is being studied afresh and as yet no definite conclusion has emerged. As regards the management of depression, the combination of anxiolytics and antidepressant drugs are being commonly used. Such combinations may be more justified in patients presenting with severe anxiety and agitation. Moreover, in certain depressive conditions combinations are especially useful; for instance, neuroleptics and antidepressants could be drugs of choice in cases of …