Unpacking the Pressing Challenges of Polypharmacy in Psychiatry

With Jo Hughes, DMSc, PA-C, CAQ-PSY

In this exclusive Q&A, Psych Congress PA Institute Pre-Conference faculty member Jo Hughes, DMSc, PA-C, CAQ-PSY, discusses the complexities of polypharmacy in psychiatry and the balance between medication management and patient safety. Delving into the risks associated with excessive prescribing, Dr Hughes highlight strategies to optimize treatment while prioritizing patient-centered care. With real-world case examples and practical tips, this discussion emphasizes the importance of collaboration and effective communication in navigating medication discontinuation.

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Editor’s note: This interview has been lightly edited for clarity.

Psych Congress Network: Can you discuss polypharmacy in psychiatry, and how clinicians can balance risks with potential benefits?

Dr Jo Hughes:

Balancing Polypharmacy Risks and Benefits

We, as prescribers, have all faced the ‘Prescriber’s Dilemma’ of differentiating between appropriate polypharmacy and inappropriate polypharmacy—essentially, deciding when “enough is enough.” The first rule [of prescribing] is to do no harm but also to help our patients to our full scope of practice; it can be tricky. This dilemma is a global health concern.

Rational Use of Medications

The rational use of prescribing medication is the right drug, in the right dose, at the right time, and by the right route. The benefits of this approach include managing multiple chronic conditions, improving symptom control, and the prevention of disease progression.

Global Considerations in Polypharmacy

Global considerations include following evidence-based practices, clinical and policy guidelines, utilizing risk-benefit analysis for the best treatment choice, and consideration of patient-specific factors such as age, comorbidities, and lifestyle. 

Risks and Issues With Excessive Prescribing

Excessive prescribing can lead to adverse drug reactions and drug-drug interactions, which are more likely with multiple providers involved. Other risks include misinterpreting adverse events as new medical issues, increased health care costs, more frequent use of emergency services, and greater long-term disability. Additionally, non-adherence, inappropriate use, and diversion of medications are common risks.

At-Risk Populations

Those at the greatest risk from polypharmacy are women, patients over 65, non-Hispanic white and non-Hispanic Black populations, lower-educated adults, and people with cardiovascular disease or diabetes. Interestingly, individuals both above and below the poverty line face similar risks.

PCN: Which pharmacokinetic factors should clinicians focus on when discontinuing psychiatric medications?

Dr Hughes:

Clinicians should focus on the following pharmacokinetic factors:

• Remember the ADME principle of pharmacokinetics: Absorption, Distribution, Metabolism, and Elimination.
• Absorption refers to how much drug (Cmax) is circulating in the blood after drug is taken, where does it go (distribution), how long does it stick around in the body (metabolism–half-life), and when/where does it get eliminated (Cmin). Essentially, what goes “up” must come “down,” and understanding these processes is important to optimize effectiveness and minimize tolerability issues.
• A key component to half-life is it can vary from person to person, gets longer with age, and is susceptible to co-administration of other medications. 

PCN: Can you share a case where polypharmacy was challenging, and how pharmacokinetics informed your approach?

Dr Hughes: A 55-year-old female presents to the clinic as new patient with unmanaged anxiety and depression with a long-history of venlafaxine use and wishes to try another medication to relieve her symptoms. I decide to try her on a novel antidepressant, dextromethorphan-bupropion, to treat her depressive symptoms. However, I needed to taper her off venlafaxine first, which is known to be challenging due to its propensity for withdrawal symptoms. I begin the taper slowly while adding low-dose fluoxetine to her regimen to minimize the effects of withdrawal from venlafaxine.

Fluoxetine has a long half-life of approximately 2 weeks compared to venlafaxine’s half-life of 3-7 hours, which contributes to the withdrawal symptoms. By utilizing fluoxetine’s half-life properties against venlafaxine’s short half-life, I can minimize negative withdrawal effects for the patient and therefore increase the future success of tapering off venlafaxine and fluoxetine completely then beginning a new trial of dextromethorphan-bupropion. 

PCN: What practical tips can help clinicians manage complex medication discontinuation in patients with multiple comorbidities?

Dr Hughes: Choose the right time for discontinuation—avoid times of crisis or acute illness. Compile a list of all medications taken, assessing drug-drug interactions, indications, current adverse and current effects, and original indications for disorder/disease states. Then start the discussion of tapering down, assessing the patient’s comfort and perceptions of each medication. Is there a true benefit versus perceived benefit? Does the same apply with harm?

Begin to introduce deprescribing plans; discuss the process step by step and write it down! Be curious and listen carefully to concerns and fears a patient may have, no matter how far-fetched or irrational it may seem to you—be a good, active listener without judgment. Remember, the prize is to reduce overall health risks to the patient, and they have relationships with some medications—it’s like they are breaking up with their long-time confidant or security blanket. It takes a finesse and confidence to help them on this journey. Also, elicit family and/or friends to encourage reduction and interest into the “plan.”

Now, specifically identify the medication on the “list” and develop the plan together. Remember, you won’t be going home with them, and they need to understand and buy-into this plan. 

PCN: Is there anything else you would like to share with the Psych Congress Network audience?

Dr Hughes: Don’t get too caught up in the “right” way to reduce or taper a patient’s medication. Remember the overall goal to deprescribing in the first place is to do no harm and help them when we can. Remember the process is a journey not a race.
 

Jo A. Hughes, DSMc, PA-C, CAQ-PSY, of Greensboro, North Carolina, is a psychiatric certified physician associate (PA) who works in an outpatient setting. She specializes in neurodevelopmental disorders in children, adolescents, and adults and has extensive training and experience in substance use disorders.

Dr Hughes completed her PA training and Master of Medical Science at Wake Forest University School of Medicine and additionally holds a Doctor of Medical Science in psychiatry from Rocky Mountain University of Health Professionals. She is a certified PA with a Certificate of Added Qualification in Psychiatry.

Dr Hughes is currently the President Elect with Association of Physician Assistants in Psychiatry (APAP) and is involved with North Carolina Association for PA’s (NCAPA) at the committee level in educating PA’s.

Jo and her husband are frequently seen visiting a non-profit coffee house they co-founded employing adults with neurodiversity in Greensboro, North Carolina.