S-14-01

Polypharmacy in schizophrenia

S. Kasper, A. Konstantinidis. Medizinische Universität Allgem. Psychiatrie, Wien, Austria

Although there is a lack of data indicating the efficacy of polypharmacy in schizophrenia there seems to be a widespread belief, not only in Europe, that the combination of antipsychotics/ neuroleptics enhances the efficacy of antipsychotic treatment. This approach, the polypharmacy approach, is specifically undertaken in the group of treatment-refractory schizophrenia. Before the introduction of the group of atypical antipsychotics the combination of high-potency neuroleptics (e.g., haloperidol) with low-potency neuroleptics (e.g., levomepromazine) was quite common practice. Sedation was the target for low-potency neuroleptics and antipsychotic efficacy for the high-potency neuroleptics. However, there seems to have been a shift in recent years for the combination of an atypical antipsychotic (e.g., clozapine) with a high-potency neuroleptic (e.g. haloperidol), although the available data base does not clearly indicate the effectiveness of this approach. For clozapine and risperidone, a few case reports and case series are available to support this type of combination treatment, which is argued to be based on pharmacodynamic considerations with the different striatal D2 receptor occupancy rates of these compounds. The combination of two atypical antipsychotics is not so much performed in Europe but seems to be the practise in Canada. Specifically the financial limitations do not favor this approach, given also the lack of available data. Controlled studies of polypharmacy, including brain imaging and molecular psychiatric parameters, need to be conducted to find out the therapeutic potential of polypharmacy approaches in schizophrenia.

S-14-02

Polypharmacy in bipolar disorder

B. Vieta. University of Barcelona Hospital Clinic, Barcelona, Spain

Objective: To address the main benefits and inconvenients of polypharmacy in the treatment of bipolar illness.

Methods: A systematic literature search was carried out. Controlled and naturalistic reports were extensively scrutinized.

Results: Bipolar disorder is difficult to treat. Only about one third of bipolar patients respond to monotherapy. For this reason, combination therapy is increasingly the rule rather than the exception. The advantage of polypharmacy, particularly when drugs with different mechanisms of action are combined, is enhanced efficacy. This is, however, not the same as enhanced effectiveness, as side effect burden and interactions may result in higher attrition rates and poor compliance. However, for a substantial proportion of patients, the skilful combination of anticonvulsants with atypical antypsychotics (in mania), antidepressants (in bipolar depression) and lithium (in prophylaxis) seems most promising. In coming years, high standard randomized controlled trials should address the specific efficacy and tolerability of certain combinations. Meanwhile, clinicians who are faced with the treatment of this disabling condition, have started to use these combinations in order to achieve better outcome for their bipolar patients.

Conclusion: While monotherapy would be the ideal therapy, the reality is pushing clinicians to combine two, three or more drugs, together with psychoeducative approaches, for many, if not most, of their patients.

S-14-03

Combinations of antidepressants with other psychotropic drugs: Evidence from naturalistic studies and randomised controlled trials

D. Baldwin. Royal South Hampshire Hospital, Southhampton, United Kingdom

Objective: Antidepressants are often combined with other psychotropic drugs in primary and secondary mental health care settings. In some instances, combination treatment may be supported by the results of meta-analysis and randomised controlled trials: in others, the rationale for combination can be unclear, and treatment associated with potential hazards.

Methods: Structured review of the relevant findings of naturalistic studies of antidepressant prescribing in primary and secondary care; appraisal of randomised controlled trials of combining antidepressants with benzodiazepines, lithium, anticonvulsants, atypical antipsychotic drugs and other compounds.

Results: Naturalistic (typically retrospective) studies indicate that antidepressants are frequently prescribed in combination with other psychotropic drugs. Meta-analyses and/or randomised controlled trials support the common clinical practice of attempting to enhance efficacy through combining lithium, and some benzodiazepines or atypical antipsychotics, with antidepressant drugs: the evidence is less strong for approaches that attempt to enhance tolerability through combination treatment. However, it is uncertain how much of clinical practice is determined by awareness of this evidence base, or is influenced by other factors.

Conclusion: There is a need for prospective naturalistic studies of the reasons for use of concomitant psychotropic medication during antidepressant treatment.

S-14-04

Is there a psychopharmacological rationale for polypharmacy?

W. Muller. Frankfurt, Germany