272
`
`Pharmacopysychiat. 21 (1988) 272-273
`© Georg ThiemeVerlag Stuttgart - New York
`
`Long-term Therapy of Affective Disorders: Monotherapy
`or Polypharmacy?
`
`W. Konig, R. Rissom, G. Kalfoglu, A. Stein, F. Reimer
`
`Psychiatric Hospital Weinsberg (Head: Prof. Dr. F. Reimer), Weinsberg, FRG
`
`Introduction
`
`In the treatment of affective disorders the use of a combined
`psychopharmacotherapy is nowadays common among physi-
`cians both in practice as well as in clinics. Analyses of prescrip-
`tions have shown that polypharmacy sometimes is used even
`more often than monotherapy (Grohmannet al., 1982; Muiller-
`Oerlinghausen, 1977; Salzmann, 1981; Schiissler et al., 1982).
`Administration of several psychotropic drugsat the same time
`might be useful for a speedier onset of relief or intensification of
`therapeutic effectiveness at the start of treatment. In long-term
`treatment, however, polypharmacy might
`lead to unwanted
`effects, such as abuse of benzodiazepines or tardive dyskinesia
`caused by neuroleptics. Besides thatit will lead to an increase of
`consumption of psychotropic drugs. The aim ofthe following
`study was, therefore, to analyse the prescription habits of the
`
`psychiatrists in a large hospital during one decade, especially in
`respect to long-term treatment.
`
`Methods and Patients
`
`Using the archives of the Psychiatric Hospital Weinsberg,all patients
`hospitalized from 1976 through 1985 diagnosed as “affective disorder”
`according to ICD-Nrs. 296 (8th or 9th revision, respectively) have been
`selected. All patients have been screened based on admission reports,
`clinical course during index treatment, and — as far as possible — on ca-
`tamnesis; patients who did not clearly meet the criteria of an affective
`disorder have been excluded. Patients selected for the study have been
`divided into three diagnostical subgroups: unipolar, bipolar, and invo-
`lutional depression. Next to sociodemographic data, medication at the
`day of discharge has been recorded, particularly dosages of antidepres-
`sant drugs and lithium. Indication for the dosageoflithium was blood
`level in mmol/l; antidepressants have been divided into low dosages
`(up to 75 mg/day ofa tricyclic antidepressant or equivalent dosages of
`
`Frequencyofaffective disorders, percentage of diagnostical subgroups and mean ageof female patients at the Psychiatric Hospital
`Table 1
`
`Weinsberg from 1976-1985
`
`1976
`
`1977
`
`Total (mean age)
`
`Involutional
`depressionin %
`(mean age)
`Unipolar depression
`in%
`(mean age)
`Bipolar depression
`in%
`(mean age)
`
`192
`(55.0)
`47.3
`(60.6)
`
`25.8
`(46.5)
`
`26.9
`(53,3)
`
`185
`(55.4}
`48.9
`(61.4)
`
`26.4
`(45.7)
`
`247
`
`(54.1)
`
`1978
`
`186
`(55.5)
`54.9
`(62.6)
`
`24.9
`(42.3)
`
`20.2
`(52.7)
`
`1979
`
`189
`(56.6)
`59.0
`(63.4)
`
`21.4
`(42.9)
`
`19.6
`(51.2)
`
`1980
`
`155
`(55.5)
`51.8
`(63.3)
`
`25.5
`(46.1)
`
`22.7
`(48.2)
`
`1981
`
`171
`(55.8)
`55.4
`(62.9)
`
`26.6
`(47.0)
`
`18.0
`(50.0)
`
`1982
`
`140
`(58.6)
`57.0
`(67.1)
`
`22.3
`(45.3)
`
`20.7
`(49.6)
`
`1983
`
`153
`(58.3)
`59.4
`(65.0)
`
`21.8
`(43.4)
`
`18.8
`(54.4)
`
`1984
`
`137
`(60.1)
`61.5
`(67.6)
`
`214
`(49.4)
`
`17.4
`(46.9)
`
`1985
`
`141
`(59.9)
`53.6
`(65.5)
`
`20.0
`(52.4)
`
`26.4
`(54.3)
`
`Table 2 Prescription of antidepressant drugs (AD) at the day of discharge; percentage of monotherapy and combined therapy with other
`psychotropic drugs (PD).
`
`1977 1976
`1978
`1979
`1980
`1981
`1982
`
`1983
`
`137
`
`1984
`
`101
`
`1985
`
`101
`
`Total number of
`prescriptions
`Monotherapy
`(in %)
`AD +1PD
`(in %)
`AD +2PD
`(in %)
`AD+3PD
`{in %)
`AD +4PD
`(in %)}
`
`157
`
`10.8
`
`61.8
`
`20.4
`
`5.7
`
`13
`
`151
`
`11.9
`
`55
`
`278
`
`46
`
`0.7
`
`162
`
`15.4
`
`54.3
`
`27.8
`
`25
`
`-
`
`159
`
`7.6
`
`579
`
`214
`
`25
`
`0.6
`
`144
`
`11.8
`
`74.3
`
`13.2
`
`0.7
`
`~
`
`132
`
`15.2
`
`58.3
`
`22
`
`45
`
`-
`
`121
`
`14.9
`
`55.4
`
`26.4
`
`3.3
`
`-
`
`10.9
`
`65.7
`
`22.6
`
`07
`
`~
`
`17.8
`
`58.4
`
`20.8
`
`3.0
`
`~
`
`9.9
`
`41.6
`
`38.6
`
`99
`
`-
`
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`1 of 2
`
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`

`

`Long-term Therapy of Affective Disorders: Monotherapy or Polypharmacy?
`
`Pharmacopsychiat. 21 (1988)
`
`273
`
`Table 3 Prescription oflithium (LI) at the day of discharge; percentage of monotherapy and combined therapy with other psychotropic
`drugs (PD)
`
`1976
`1977
`1978
`1979
`1980
`1981
`1982
`1983
`1984
`1985
`
`
`Total number
`of prescriptions
`Monotherapy
`(in %)
`Li+1PD
`(in %)
`LI+2PD
`(in %)
`LI+3PD
`(in %)
`LI+4PD
`(in %)
`
`49
`
`6.1
`
`38.8
`
`38.8
`
`14.3
`
`2.0
`
`44
`
`68
`
`15.9
`
`56.8
`
`18.2
`
`35
`
`2.9
`
`17.1
`
`543
`
`25,7
`
`26
`
`-
`
`42.3
`
`50.0
`
`77
`
`27
`
`14.1
`
`40.7
`
`444
`
`3.8
`
`25
`
`-
`
`32.0
`
`48.0
`
`20.0
`
`17
`
`-
`
`35.3
`
`53.0
`
`17
`
`27
`
`-
`
`44.4
`
`51.9
`
`3.7
`
`15
`
`6.7
`
`33.3
`
`40.0
`
`20.0
`
`18
`
`-
`
`16.7
`
`444
`
`38.9
`
`2.3
`-
`-
`-
`~
`-
`-
`-
`-
`
`
`non-tricyclic antidepressants, respectively), average dosages (75-150
`mg/day), and high dosages (more than 150 mg/day). All together 3835
`admission reports have been reviewed. In order to warrant distinction
`ofdata, results will be presented of female patients only, who represent
`67-75% ofall patients.
`
`Results
`
`Table | shows for 1976 through 1985 the frequency of female
`patients admitted as well as the percentages of the diagnostic
`subgroups, both with respective mean ages. The proportion of
`patients with involutional depression shows, on average, a
`slight increase.
`The total increase of mean age by approximately 5 years was not
`only caused by the higher proportionofpatients with involutio-
`nal depression since the mean age ofpatients with unipolar de-
`pression increased as well.
`At the day of discharge mostly two or three different psychotro-
`pic drugs were administered as maintenance therapy (55-90%
`of all patients), less than 1% of the patients had five different
`psychotropic drugs, less than | % had none. Table 2 shows the
`relative frequency of combinations of antidepressants with
`other psychotropic drugs. From all patients discharged with an
`antidepressant as main therapeutical strategy, on the average
`only 10-15% were treated in monotherapy. 55-75% were
`discharged with a combination therapy with one other drug; up
`to 1983 mostly a low potency neuroleptic was added,as of 1984
`a benzodiazepine.
`Approximately 20% of the patients were discharged with three
`different drugs; upto the late seventies primarily with a neuro-
`tropic drug plus a low potency neuroleptic, as of the early
`eighties with a benzodiazepine and a low potency neuroleptic.
`During the decade researched, dosages of antidepressants were
`mostly low (46-58%) or average (40-46%), high dosages were
`unusual (0.8-7.4%).
`Table 3 showsthe frequenciesoflithium prescriptions; during
`the whole period there was a continual decrease. Monotherapy
`wasrarely used and there was a tendency to administerlithium
`in combination with two other psychotropic drugs, either with
`an antidepressant and a low potency neuroleptic or with a high
`potency and a low potency neuroleptic.
`Lithium bloodlevels at the day of discharge wererelatively con-
`stant throughoutthe decade, 0.56—0.70 mmol/1 (mean 0.66).
`
`Discussion
`
`On comparing prescription habits of antidepressants and
`lithium for long-term treatmentofaffective disorders at a large
`psychiatric hospital some remarkable changes were found. The
`dosages of antidepressants and lithium on the day of discharge
`remained nearly the same. Monotherapy wasrarely used, the
`numberoflithium prescriptions even decreased. On the other
`hand, the percentage of combination therapy clearly increased,
`so that after all the amountof psychotropic drugs administered
`really did increase. Of particular interest is the fact that alt-
`hough general prescriptions of benzodiazepines decreased
`within the last years (Wissenschaftliches Institut der Ortskran-
`kenkassen, 1985), we found a higher rate of benzodiazepine
`prescriptions since 1984.
`As we carried outa retrospective study, it was of course not pos-
`sible to investigate the patients’ compliance and whetheror not
`the drugs were prescribed further more. Therefore it was impos-
`sible to find outif long term consumption of psychotropic drugs
`really increased, but it probably did.
`During the last years consumption of psychotropic drugs has
`been discussed from a morecritical point of view, so that redu-
`cing prescription ofdifferent drugs at the same time might be an
`appropriate contribution to rational psychopharmacotherapy.
`To find outif there is a continuing tendency for polypharmacy
`at our hospital will be the subjectof further research.
`
`References
`Grohmann, R., A. Strauss, Ch. Gehr, E. Riither, H. Hippius: Zur Praxis
`der klinischen Therapie mit Psychopharmaka. Pharmacopsych-
`iatry 18, Karger Basel 1982.
`Miiller-Oerlinghausen, B.: Mehrfachmedikation bei Therapie und
`Prophylaxe
`depressiver Erkrankungen.
`In: H. Helmchen
`(Hrsg.): Depressive
`Syndrome.
`E.
`Banaschewski-Verlag
`Miinchen 1977.
`Salzmann, C.: Psychotropic drug use and polypharmacyin a general
`hospital. Gen. Hosp. Psychiatry 3 (1981) 1-9
`Schiissler, G., M. Linden, I. Otten: Patienten in der nervenarztlichen
`Praxis. Nervenarzt 53 (1982) 537-543.
`Wissenschaftliches
`Institut der Orstkrankenkassen: Pharmakolo-
`gisch-therapeutische Analyse der Kassendrztlichen Arzneiver-
`ordnungen in der Bundesrepublik Deutschland. Bonn 1985.
`
`Dr. W. Kénig, Psychiatrisches Landeskrankenhaus Weinsberg, D-7102 Weinsberg, FRG
`
`2 of 2
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`2 of 2
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`Alkermes, Ex. 1070
`
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