Category: Psychopharmacology



If you find yourself prescribing neuroleptics for a mood disorder, mood stabilizers for a psychotic disorder and antidepressants left and right for all sort of NOS diagnoses it’s not a bad idea to take a deep breath and a hard look at your diagnoses.

Not that we never prescribe mood stabilizers for schizophrenia, or (in this brave new age of second generation everything) atypicals for mood disorders. We do.

However, even during these times of a relaxed psycho-pharmacology, an understanding of first versus second line, switching and augmenting is still a sine qua non of good doctoring.  Which implies that when your psychotropic does not closely match your patient’s diagnosis you’d better have a good explanation of why that is.

And it wouldn’t hurt either to document it accurately so that the next doctor in line or yourself looking at your old notes will understand your rationale for prescribing outside the standard of care.

You should consider also reviewing and/or appropriately documenting your drug dispensing habits for your patients on major poly-pharmacy type of cocktails. Remember that the evidence base for most poly-pharmacy type of strategies is rather flimsy, while the evidence base for compounded toxicity is gaining momentum.Bottom line: prescribing more than one medication for an indication is not the best charted territory, which by the way includes the unclear evidence-based realm of augmentation strategies.

Red flag combinations? Two or more similar agents prescribed together. This includes , going from rather non-nonsensical to somewhat explainable combinations (and I list here only combinations that I’ve actually seen): two SSRIs, tow SNRIs, SSRI + SNRI, two stimulants, two TCAs, two typical neuroleptics, two atypical neuroleptics, typical + atypical neuroleptic, two mood stabilizers (other than lithium).

Make sure that your medications match your diagnosis and that you have a good rationale for each medication you dispense to a patient.


An interesting instance where practice has not been particularly supported by evidence.
Hopefully this new paper by Essock et al. is just a beginning. When it comes to polypharmacy, Essock et al concludes that there is “some evidence support[ing] a combination of antipsychotics and antidepressants for negative symptoms and comorbid major depressive episodes”. And that is pretty much all there is.

In other words:

No clear evidence for piling antipsychotics on the top of each other, which is common practice, or even for mood stabilizer augmentation.

Now, the problem with schizophrenia is that for most of the cases that end up in our clinics or hospitals, more often than not, we are looking at some degree of partial response. In clinical parlor these are the so called “treatment-refractory cases”.

And labels do matter: as one might need to carefully re-think their whole treatment plan when the problem is partial response, while “creative approaches” (i.e. not evidence based) are acceptable if the problem is defined as treatment residence. In other words, when the treatment refractory/resistance territory is seen as the medical equivalent of the Far West, with uncontrolled pathology looming darkly over the patient’s and doctor’s heads, shooting from the hip might be seen as actually the right thing to do. However, in medicine cowboyish approaches are never the right thing to do.

Essock et al. take home point? Think twice about combining medications.  The benefits are unclear, while the compounded toxicity is certain!

Just another reminder that conservative medicine is better medicine.


1. Course: ADHD is chronic versus bipolar: episodic. Which also means that you should see ADHD signs during exam, while we might or might not see signs of bipolar on presentation.

2. Long time prognosis: ADHD might get better with time while bipolar tends to get worse with time.

3. Drugs of abuse: ADHD: “cocaine (in general uppers) slow me down”. Bipolar: “I use uppers when I am down, downers when I am hyper”.

4. Family history: bipolar patients have more of a loaded fam hx in terms of affective and psychotic disorders.

5. When in doubt, safety comes first: assume and treat as bipolar (i.e. mood stabilizer) as while this will help a bipolar patient; at the same time, it might not help it would also not harm an ADHD patient. Stimulant first when in doubt is a risky choice: while it would help an ADHD patient, it will also hurt a bipolar patient who will escalade straight into severe mania.


Common scenario:

Patient has been doing well on meds. All of a sudden no longer doing well.

What’s happening?

Hypothesis: The medication(s) stopped working.

Possible explanations:

1. Medication(s) all of a sudden became ineffective. What’s the chance of that? Small.

2. Patient stopped taking the medication(s) as prescribed. What’s the chance of that? High.

Solution: Make sure compliance is optimal BEFORE considering medication changes.

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