Category: Psychotic Disorders

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.


Look for:

1. Independent psychotic symptoms

2. Historical and quantitative predominance of affective symptoms: e.g. “for most of my life I’ve been depressed/hyper”; “yes, I do hear voices but my major problem is not the voices but my depression. That’s what always gets me hospitalized”.

3. Rapid decompensations and rapid response to meds. Schizophrenia tends to be fairly chronic. Even when it presents with more of an episodic course it is still typically slow to take off and then get under control.

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