Phannacopysychiat. 21 (1988) 272-273
`© GeorgThiemeVerlagStuttgart - New York
`
`Long-term Therapy of Affective Disorders: Monotherapy
`or Polypharmacy‘?
`
`W. Kiinig, Fl. Flissom, G. Kalioglu, A. Stein, F. Reimer
`
`Psychiatric Hospitai 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 [Grohmarm et al., 1932; Midter-
`Oerfinghausen, I977: Safzmarm. 198i; Schiimler et al., I932).
`Administration of several psychotropic drugs at the same time
`might be useful fora speedieronset of reliefor intensification of
`therapeutic effectiveness at the start oftreatment. In long—term
`treatment. however, polypharmacy might
`lead to unwanted
`effects. such as abuse of benzodiazepines or tardive dyskinesia
`caused by neuroleptics. Besides that it will lead to an increase of
`consumption of psychotropic drugs. The aim of the 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 Pariems
`
`Using the archives of the Psychiatric Hospital Weinsberg, all patients
`hospitalized from 1916 through 1985 diagnosed as “affective disorder“
`according to ICD-Nrs. 296 (3th 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 ciearly 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. particulariy dosages of antidepres-
`sant drugs and lithium. lndication forthe dosage of lithium was hlood
`level in mmolflz antidepressants have been divided into low dosages
`(up to 15 mg/day of a tricyclic antidepressant or equivalent dosages of
`
`Frequency of affective disorders. percentage of diagnostical subgroups and mean age of female patients at the Psychiatric Hospital
`Table 1
`Weinsberg from 19738-1985
`
`Total (mean age]
`
`Involutional
`depression in "/3
`(mean age}
`Unipolar depression
`in "/3
`(mean age]
`Bipolar depression
`in “/3
`(mean age)
`
`1976
`
`192
`(55.0)
`47.3
`(60.5)
`
`25.8
`(46.5)
`
`26.9
`(53.3)
`
`197?
`
`185
`(55.4)
`48.9
`(61.4)
`
`25.4
`(45.7:
`
`24.7
`(54.1)
`
`19738
`
`186
`(55.5)
`54.9
`(62.6)
`
`24.9
`(42.3)
`
`19119
`
`139
`155.5}
`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.?
`(48.2)
`
`1981
`
`171
`(55.8)
`55.4
`(62.9)
`
`26.6
`[4?.0]
`
`18.0
`(50.0)
`
`1982
`
`140
`(58.6)
`57.0
`(67.1)
`
`22.3
`(45.3)
`
`20.?
`(49.6)
`
`1983
`
`153
`(58.3)
`59.4
`(65.0)
`
`21.8
`(43.41
`
`13.3
`154.4}
`
`1984
`
`137
`(60.1)
`61.5
`(616)
`
`21.1
`(49.4)
`
`17.4
`(46.9)
`
`1985
`
`141
`(59.9)
`53.6
`(85.5)
`
`20.0
`(52.4)
`
`25.4
`(54.31
`
`20.2
`(52.7)
`
`Table 2 Prescription oi antidepressant drugs (A0) at the day of discharge; percentage of rnonotherapy and combined therapy with other
`psychotropic drugs (PD).
`
`19?8
`
`157
`
`10.8
`
`51.8
`
`20.4
`
`5.?
`
`1 3
`
`Total number of
`prescriptions
`Monotherapy
`(in %l
`AD + 1 PD
`(in ”/ul
`AD + 2 PD
`(in %l
`AD + 3 PD
`[in "/cl
`AD + 4 PD
`(in 9'9}
`
`1977
`
`151
`
`11.9
`
`55
`
`19?8
`
`162
`
`15.4
`
`54.3
`
`19?9
`
`159
`
`17.6
`
`5?.9
`
`21.4
`
`2.5
`
`0.6
`
`1980
`
`144
`
`1981
`
`132
`
`15.2
`
`58.3
`
`22
`
`4.5
`
`1982
`
`1983
`
`137
`
`10.9
`
`65.?
`
`121
`
`14.9
`
`55.4
`
`26.4
`
`3.3
`
`1985
`
`101
`
`9.9
`
`1984
`
`101
`
`1?.8
`
`58.4
`
`20.8
`
`Alkermes, Ex. 10
`
`1 of 2
`
`Alkermes, Ex. 1070
`
`

`
`Long-ten'n Therapy of Affective Disorders: Monotherapy or Polyphannacy?
`
`Pharmacopsychiat. 21 { I 988)
`
`273
`
`Table 3 Prescription of lithium [Ll] at the day of discharge; percentage oi monotherapy and combined therapy with other psychotropic
`drugs {PD}
`
`1 976
`
`1 97?
`
`49
`
`6.1
`
`44
`
`5.8
`
`1978
`
`35
`
`2.9
`
`1 979
`
`26
`
`1980
`
`27
`
`1981
`
`25
`
`1982
`
`1 7
`
`1983
`
`27
`
`1985
`
`18
`
`1984
`
`15
`
`6.7
`
`33.3
`
`Total number
`of prescriptions
`Monotherapy
`{in %l
`Ll + 1 PD
`tin %t
`Ll + 2 PD
`(in "/at
`LI + 3 PD
`{in %l
`LI + 4 PD
`{in %l
`
`non-tricyclic antidepressants, respectively), average dosages ('?S—lS[}
`mgfday}, and high dosages (more than 150 mgrdayl. All together 3335
`admission reports have been reviewed. in order to warrant distinction
`of data, results will be presented of female patients only, who represent
`67-75% of all patients.
`
`Results
`
`Table I shows for I976 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 involutiortal depression shows, on average, a
`slight increase.
`The total increase of mean age by approximately 5 years was not
`only caused by the higher proportion of patients with involutio-
`nal depression since the mean age of patients 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 l% 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 l0—| 5 % were treated in monotherapy. 55-15 % 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; up to 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—?.4%}.
`Table 3 shows the frequencies of lithium prescriptions; during
`the whole period there was a continual decrease. Monotherapy
`was rarely used and there was a tendency to administer lithium
`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 blood levels at the day of discharge were relatively con-
`stant throughout the decade, 0.56-0.70 mmolfl (mean 0.66).
`
`Dt'sc'usst'0n
`
`On comparing prescription habits of antidepressants and
`lithium for long-tenn treatment of affective 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 was rarely used, the
`number of lithium prescriptions even decreased. On the other
`hand, the percentage of combination therapy clearly increased,
`so that after all the amount of 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 0t1skran-
`kenkassen. I985), we found a higher rate of benzodiazepine
`prescriptions since I984.
`As we can-ied out a retrospective study, it was of cou rse not pos-
`sible to investigate the patients‘ compliance and whether or not
`the drugs were prescribed further more. Therefore it was impos-
`sible to find out if long term consumption ofpsychotropic drugs
`really increased, but it probably did.
`During the last years consumption of psychotropic drugs has
`been discussed from a more critical point ofview, so that redu-
`cing prescription ofdifferent drugs at the same time might be an
`appropriate contribution to rational psychopharmacotherapy.
`To find out ifthere is a continuing tendency for polyphannacy
`at our hospital will be the subject of further research.
`
`R tgferences
`
`Grohmarm. R .. A. Strauss, Cit. Gehr. E. Rtiirher, H. Ht'ppt'us.'Zur Praxis
`der klinischen Therapie mit Psychopharmaka. Pharmaoopsych-
`iatry 18, Karger Basel 1982.
`Milifl‘er-Oerlinghausen. 3.: Mehrfachrnedikation bei Therapie und
`Prophylaxe
`depressiver Erkranltungen.
`In: H. Helmchen
`(Hrsg.): Depressive
`Syndrome.
`E.
`Banaschewslti-Verlag
`Miinchen 197?.
`Salzmann. C.: Psychotropic dmg use and polypharmacy in a general
`hospital. Gen. Hosp. Psychiatry 3 {I981} I-9
`Schiissler. G.. M. Linden. 1. (Juan: Patienten in der nerveniirztlichen
`Praxis. Nervenatzt 53 (I932) 537-543.
`PhaI'I'naltolo—
`Wissenschaftliches
`lnstitut der Orstltranltenkassen:
`gisch-therapeutische Analyse der Kasseniirztlichen Arzneiver-
`ordnungen in der Bundesrepublik Deutschiand. Bonn 1935.
`
`Dr. W. Kolrtig. P5yt.‘hfatrfsches Landeskrartkenhaus Wet'n.rberg. D-7102 H/efnsberg. FRG
`
`2of2
`
`Alkermes, Ex. 10
`
`2 of 2
`
`Alkermes, Ex. 1070