Irrational Polypharmacy

I really don't get all of this irrational polypharmacy other than to say there's too many idiots out there with a license to practice.

Some polyphmarmacy makes sense if you know the specifics of the case. E.g. I've had a few patients where several meds were tried and only a specific combination that seemed odd worked. These cases are rare. In long-term psych units with treatment-resistant cases I've had to do regimens such as the following only after trying several meds by themselves or in a 2 med combination only to fail:
Olanzapine 40 mg Q HS
Depakote 1000 mg Q BID
Lithium 600 mg Q BID
Haldol 10 mg Q BID

But these were very treatment resistant cases and I've never had such a case in private practice unless I got these patients already started on a similar regimen by someone else and I was able to always wean them off many of the meds or they had panic disorder or OCD. I did get legitimate polypharm cases in community practice because I was running a forensic ACT team (people who were found not guilty by reason of insanity, stayed in the hospital for years, but were fine in the hospital and discharged by a judge).

If the patients were stable for several months I even tried to slowly wean off some of the meds only to find that they got worse, e.g. "Doc I appreciate what you're doing but when you lowered the Haldol down to 15 mg a day the voices came back."

So what I'm saying is that polypharm can be legitimate but these cases are very very rare and usually only in forensic, long-term care, and community practice settings.

I know of five doctors that specifically started patients on 5 meds on the first visit, all at dosages not recommended at starting dosages such as...
Abilify 30 Q daily
Paxil 40 mg Q daily
Cogentin 2 mg Q BID
Zyprexa 10 mg Q HS
Clonazepam 2 mg Q BID

and some of these patients had nothing severe with them. I even asked one of those doctors why they were doing this and she smiled at me and said "you know." I replied, "no I don't know." She told me how I was young and idealistic and when I get older I'll be doing what she's doing.

I wish I could've put that encounter on video and video-shamed her to the community.

One other polypharm type of patient I've seen and this is the only type I've seen in private practice would often go like this.
1-Got them on the maximum dosage of an SSRI. It would lower the panic attacks from something to many a day to a few a month.
2-Added Buspirone and raised it to the max, lowered them more but pt still had them.
3-Add Beta-blocker. Again lowered it but pt still has a few a month
4-Then add benzo PRN at only an amount of 1-2 more than the number of panic attacks per month.

e.g. Pt is now down to maybe about 3 panic attacks a month so I'd give Ativan 1 mg PRN for a panic attack only 5 pills per month.

When patients were stable on this regimen with no evidence of substance abuse I started giving it out 30 at a time because it was a big pain in the butt for them to go to the pharmacy monthly when they were not abusing the med. Patients also had to sign contracts where they stated they understood that benzos are addictive and that if they were not responsible with the med I'd have to stop prescribing it.

Such a pt would have the following regimen:
Citalopram 40 mg Q daily
Buspirone 30 mg Q BID
Propranolol 200 mg Q BID
Ativan 1 mg Q daily PRN anxiety #5/month

As for OCD, in severe cases, I've been able to get them under control (except for 1 case where I was going to refer the patient for psycho-surgery) but I was never able to get the patient completely symptom free from OCD. Such patients would get to max dosage of an SSRI, Buspirone and a low dose atypical because data shows atypicals help OCD but at low dosages as augmentation agents.

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Irrational Polypharmacy