Persistent Antipsychotic Polypharmacy and Excessive Dosing in the Community Psychiatric Treatment Setting: A Review of Medication Profiles in 435 Canadian Outpatients

Objective: The present study aimed (1) to determine the proportion of patients treated with persistent antipsychotic polypharmacy in an outpatient population and (2) to determine if persistent antipsychotic polypharmacy is associated with excessive dosing.

Method: Using a province-wide network that links all pharmacies in British Columbia, Canada, to a central set of data systems, we identified community mental health outpatients who had been treated with the same pharmacologic regimen for at least 90 days. Apart from antipsychotics, data collection included anticholinergics, antidepressants, mood stabilizers, benzodiazepines, lipid-lowering agents, and antidiabetic agents. Demographic data including sex, age, and diagnosis were obtained from the patient’s chart. In order to compare dosages of the various antipsychotics we used a fixed unit of measurement based on dividing the prescribed daily dose (PDD) by the defined daily dose (DDD). A PDD/DDD ratio greater than 1.5 was defined as excessive dosing.

Results: Four hundred thirty-five patients met the inclusion criteria and were included in the analysis. Overall, the prevalence of persistent antipsychotic polypharmacy was 25.7% for the entire cohort. The prevalence of persistent antipsychotic polypharmacy was highest for patients with schizoaffective disorder (33.7%), followed by schizophrenia (31.7%), psychosis not otherwise specified (20.0%), bipolar disorder (16.9%), and major depression (14.3%). The mean‘ ‰±‘ ‰SD PDD/DDD ratio for all patients prescribed persistent antipsychotic polypharmacy was not only excessive, it was significantly greater compared to that of patients receiving antipsychotic monotherapy (1.94‘ ‰±‘ ‰0.12 vs 0.94‘ ‰±‘ ‰0.04, P‘ ‰<‘ ‰.005).

Conclusions: Using a diagnostically heterogeneous outpatient population, this study is, we believe, the first to report that persistent antipsychotic polypharmacy is associated with excessive dosing, in and of itself as well as compared to antipsychotic monotherapy.

J Clin Psychiatry

Submitted: November 22, 2008; accepted January 9, 2009.

Online ahead of print: March 9, 2010 (doi:10.4088/JCP.08m04912gre).

Corresponding author: Ric M. Procyshyn, PhD, British Columbia Mental Health & Addictions Research Institute, A3-113, 938 W 28th Ave, Vancouver, British Columbia, Canada, V5Z 4H4 (rprocyshyn@bcmhs.bc.ca).