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Bar News - March 23, 2001 Understanding a Client's Need for Multiple Medications By: Dr. David Schopick RECENTLY, AS A board-certified forensic psychiatrist, I was asked to perform a second opinion on a juvenile who was facing a CHINS petition. The juvenile was in psychiatric treatment with a colleague and was being prescribed four different medications. The presiding judge expressed shock at the number of medications that this young girl was taking and insisted on a second opinion. In psychiatry, we call this practice of multiple medications "polypharmacy." This practice is not unusual. With newer and safer medications, it is becoming for experienced psychiatrists to prescribe such combinations for more complicated patients. The following is an explanation as to the rationale behind polypharmacy as it becomes increasingly observed in the legal system. ‘Polypharmacy’ defined Polypharmacy is a term used to describe the prescription of a number of psychotropic medications simultaneously. Polypharmacy generally involves a mixture of medications from different categories. It should reflect a step-by-step, logical approach towards treating targeted symptoms. Polypharmacy generally involves the use of medications that have different neurotransmitter profiles. The goal is to cover one neurotransmitter (brain chemical transmitter) system, allow adequate time to assess effectiveness, then add another medication with a completely different neurotransmitter profile. Though a person may end up on four or five different medications, each one generally has a unique effect, has limited overlap with the other medications and has limited drug interactions. At times, an added medication may be used to increase, or potentiate, the effect of a medication that is already being prescribed. For example, the more common approach to treatment of major depression in a patient would be to start with an antidepressant. Most commonly, this will first involve an antidepressant with a potent serotonergic effect (an SSRI). If this does not adequately treat the depressive symptoms, the clinician may switch antidepressants (and avoid polypharmacy), or may choose to add on an antidepressant that increases dopamine and norepinephrine activity. In this case, the polypharmacy involves the use of two antidepressants simultaneously, but they each work on very different mechanisms. In other words, they complement each other. After an antidepressant is considered to have inadequate benefit, the physician may add on medications from other families of medications. If anxiety is a predominant symptom, then a benzodiazepine such as Klonopin or Ativan may be added. An alternative antianxiety (anxiolytic) medication that increases serotonergic activity and may enhance the effect of an SSRI is Buspirone (Buspar). If the patient complains of intolerable mood swings, then a mood stabilizing medication is often added. The most commonly used medications in this category include lithium, Depakote, Neurontin, Trileptal and Tegretol. The mechanism for lithium is not well understood, but may involve an effect on the "G protein" and sodium channels. Depakote and Neurontin are anticonvulsants that increase Gamma Aminobutyric Acid (GABA) and improve cell membrane stabilization. Other anticonvulsants that can be tried include Gabatril, Lamictal and Topamax. These latter medications are not as frequently used in psychiatry and therefore would not be considered "first line." Interestingly, the anticonvulsants are increasingly being used in the treatment of chronic pain. Thus, these medications may be part of the treatment regimen for this reason and not for mood instability. If the patient has psychotic symptoms, or requires a stronger medication for mood stabilization or relaxation, then an antipsychotic medication could be added. The older antipsychotics are called "typical antipsychotics." These work primarily by blocking Dopamine activity only. These medications are capable of causing significant side effects, some of which involve short term or permanent movement disorders. Medications in this class include Trilafon, Haldol, Thorazine, Stelazine and Prolixin. A new class of antipsychotic medications is referred to as the "atypical antipsychotics." Though much more expensive than the older "typical" antipsychotics, they presently are the first choice for prescription due to their superior safety profiles. These medications have a unique mechanism of action. They block both dopamine and serotonin activity. By blocking dopamine, they have similar effects to the typical antipsychotics. By blocking serotonin, they prevent inhibition of dopamine release in certain areas of the brain. This allows for an increase in dopamine activity in the areas of the brain associated with the movement disorders that the typical antipsychotics cause. As a result, the movement disorders associated with the "typical antipsychotics" are much less likely to occur. Atypical antipsychotics include Clozaril, Risperdal, Seroquel and Zyprexa. Logical strategy of multiple medications It is reasonable for a patient with a difficult-to-treat psychiatric illness to be on a number of medications simultaneously. Each medication will commonly represent a different class of medication that will involve a separate mechanism of action. The more common polypharmacy regimens might involve one antidepressant, one mood stabilizer, one antipsychotic, and one anxiolytic. If more than one antidepressant is used at one time, the second medication is generally chosen for a specific reason. This can include a unique action that would enhance or complement the initial antidepressant. It is uncommon to use two or more anticonvulsants simultaneously. The reason for this is that most are metabolized by the liver and are protein bound. Simultaneous usage will cause competition for liver enzymes during metabolism and competition for protein binding sites. This interaction makes the simultaneous usage of two or more anticonvulsants more complicated. If a second mood stabilizer were used, it typically would involve the addition of an anticonvulsant that has a low likelihood for drug interaction with the first. An exception is neurontin, which is excreted by the kidneys. The use of one anticonvulsant that is eliminated by the kidneys and one that is eliminated by the liver is less complicated in terms of managing blood levels and effectiveness. Polypharmacy must reflect a well thought-out strategy. This strategy needs to address target symptoms, mechanism of actions, metabolism or clearance of medications, the potential for drug interactions, and side effects. It has become increasingly necessary for more impaired and troubled individuals to be medicated with more than one medication simultaneously. Judges and attorneys need not be surprised when confronted with such combinations in a client’s records. However, the clinical record must provide adequate justification for the use of such regimens. Forensic psychiatrists can be of assistance to the courts and individual attorneys in determining the appropriateness of such combinations. David Schopick, MD is board-certified by the American Board of Psychiatry and Neurology in child, adolescent, and adult psychiatry with subspecialty certification in forensic psychiatry. He is certified in psychopharmacology by the American Society of Clinical Psychopharmacology. He practices in Portsmouth. |
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