Clinicians' Reasons for Antipsychotic Coprescribing

Michael J. Sernyak, M.D., and Robert Rosenheck, M.D.

Background: Prescribing more than 1 antipsychotic is common but has received little supportive evidence in the literature. This study was designed to systematically survey clinicians about their rationale for prescribing more than 1 antipsychotic for specific patients.

Method: Patients with schizophrenia (diagnosed according to ICD-9 criteria from October 1, 1999, to September 30, 2000) at 2 Veterans Administration (VA) medical centers and their prescriptions for antipsychotics (filled within the VA system from June 1, 2000, through September 30, 2000) were identified from administrative databases. Clinicians for each patient with more than 1 antipsychotic prescription were interviewed using a structured questionnaire. After summarizing offered explanations, we compared patients prescribed 2 atypicals with those prescribed an atypical and a conventional.

Results: The treatment of 66 patients was reviewed. The 4 most common reasons for coprescription were reducing positive symptoms (61%), reducing negative symptoms (20%), decreasing total amount of medication (9%), and reducing extrapyramidal symptoms (5%). In 65% of patients (41/63), psychiatric symptoms were thought to have been refractory to antipsychotic monotherapy. In 39% of patients (N = 26), antipsychotic coprescription was intended to be transitional, but in only 46% of these patients (N = 12) had this transition been completed after 6 to 12 months.

Conclusion: Prescribers for patients receiving more than one antipsychotic were frequently able to cite plausible and specific target symptoms they were attempting to address with this practice.

(J Clin Psychiatry 2004;65:1597-1600)

Received Jan. 14, 2004; accepted May 27, 2004. From Psychiatry Service, VA Connecticut Healthcare System, West Haven, and the Department of Psychiatry, Yale University School of Medicine, New Haven (Dr. Sernyak), and VA Northeast Program Evaluation Center, West Haven, and the Department of Psychiatry, Yale University Schools of Medicine and Epidemiology and Public Health, New Haven (Dr. Rosenheck), Conn.

This work was supported by the Department of Veterans Affairs VISN 1 Mental Illness Research and Clinical Center, West Haven, Conn.

Dr. Sernyak has received grant/research support from AstraZeneca and honoraria from Pfizer, Janssen, and Eli Lilly. Dr. Rosenheck is a consultant to and serves on the speakers or advisory board for Bristol-Myers Squibb and is an employee of and has received grant/research support from the Veterans Administration.

The authors thank Charles Drebing, Ph.D., David Dausey, Ph.D., and Lynn Gordon, R.N., for their help in questionnaire design and data acquisition.

Corresponding author and reprints: Michael J. Sernyak, M.D., Psychiatry Service, 116A, VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Avenue, West Haven, CT 06516 (e-mail: michael.sernyak@yale.edu).