FINDINGS FROM THE ASCP PRESIDENTIAL TASK FORCE ON PSYCHOTROPIC DRUG POLYPHARMACOTHERAPY

Prescribers often undertake combination polypharmacy regimens for serious mental illnesses (SMIs) when monotherapies or simpler drug pairings are not efficacious. However, there has been little systematic research to inform best practices for devising combinations of 3 or more psychotropic medications. Numerous factors bear on the crafting of polypharmacy regimens, including the recognition of pharmacodynamic synergies versus mechanistic redundancies, avoiding contradictory drug mechanisms of actions and potential toxicity states, pharmacokinetic drug-drug interactions and drug dosing implications, cumulative burden of adverse effects and impact on adherence and cost, patient preference, differential intended symptom targets when treating complex or comorbid conditions, augmentations before dose optimization of single agents, and milestone decision points when opting to switch versus augment an existing treatment. To shed greater light on these issues, the ASCP undertook a presidentially-appointed task force comprised of 60 international psychopharmacology experts, including clinical trialists, psychopharmacology educators and investigators, academic pharmacists, psychiatrists, and authors of previous practice guidelines. A Delphi survey queried panelists’ attitudes and beliefs about decisions to initiate combination pharmacologies, focusing on identifying patient candidacy and criteria for polypharmacy treatments, recognizing drug mechanisms and drug-drug interactions, timing sequential versus simultaneous augmentation strategies, controversies involving the combining of atypical antipsychotics, and issues of safety and tolerability. This workshop will provide a brief historical perspective on the evolution of polypharmacy within psychiatry, and then present key findings from the Delphi survey responses and task force members’ consensus recommendations, as an impetus to generate group discussion through interactive audience participation that will provide both knowledge about polypharmacy decision-making to participants as well as feedback to the task force as it finalizes its ultimate recommendations on behalf of the ASCP to the broader scientific community as well as the general public.

Learning Objective 1: Differentiate polypharmacy combinations that are rational from irrational, evidence-based from non-evidence-based, and safe or unsafe, across major psychiatric disorders

Learning Objective 2: Recognize when, how, and why specific combination pharmacotherapy approaches are or are not likely to produce better clinical outcomes for patients with serious mental illnesses.

References

Zigman D, Blier P. A framework to avoid irrational polypharmacy in psychiatry. J Psychopharmacol 2012 Dec;26(12):1507-11.