ANTIPSYCHOTIC POLYPHARMACY IN FIRST-EPISODE PSYCHOSIS: EPIDEMIOLOGY, ASSOCIATED ADVERSE-EFFECTS AND DOSE-ADJUSTMENTS IN A TERTIARY PSYCHIATRIC HOSPITAL
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Keywords
antipsychotic polypharmacy; first-episode psychosis; metabolic syndrome; extrapyramidal symptoms; prescribing patterns; Pakistan; Khyber Pakhtunkhwa
Abstract
Background: First-episode psychosis is a critical treatment period, and combined usage of two or more antipsychotic medicines (antipsychotic polypharmacy, APP) remains frequent, despite the lack of evidence and formulation of guidelines that do not encourage it. In the province of Khyber Pakhtunkhwa in Pakistan, there is little information on the way the doctors prescript the medicine and the impact it has on a patient who has never undergone a treatment.
Methods: We reviewed the medical histories of 200 patients (aged 18 -45) diagnosed with the first episode psychosis at Khyber Teaching Hospital, Peshawar, in the period between January 2022 and December 2023. We noted the type of medicines they received, amount of each medicine, their side effects, changes in symptoms, and the changes in treatment during one year. The primary measure that we used was the number of patients who were on two or more antipsychotics at 3, 6 and 12 months. We also counted the number that got metabolic syndrome, extrapyramidal symptoms (EPS), who discontinued treatment and dosage changes.
Results: Initially, 12% of the patients received two or more antipsychotics. This increased to 38 percent, 47 percent and 52 percent after 3, 6 and 12 months. Polypharmacy patients consumed more medication on average (628 mg of chlorpromazine equivalent per day) than one medicine (412 mg) and the difference was significant. In the polypharmacy group, 34% and the one-medicine group 18% had metabolic syndrome. The percentage of extrapyramidal symptoms was 56 in the polypharmacy group and 32 in the one-medicine group. Polypharmacy was associated with the use of clozapine, resistance to treatment and prolonged hospitalization (42 days vs. 28 days) without subsequent symptom improvements (42 percent reduction in PANSS scores vs. 39 percent when using one medicine, no significant difference).
Conclusion: In first-episode psychosis, polypharmacy Antipsychotics are highly prevalent and rapidly rise in Khyber Teaching Hospital. It is associated with a higher number of metabolic and neurological side effects but is not better in effectiveness. We greatly require systematic reviews, prescriber training and evidence-based guidelines to enhance medicine use among these patients.
References
2. Chaudhri, K. (2024). Optimising use of cardiovascular medications (Doctoral dissertation, UNSW Sydney).
3. Correll, C. U. (2025). Long-acting injectable antipsychotics for patients with first-episode and early-phase schizophrenia: still not considered often enough. CNS spectrums, 30(1), e66.
4. Docrat, S. (2020). Economic costs, impacts and financing strategies for mental health in South Africa.
5. Gallego, J. A., Nielsen, J., De Hert, M., Kane, J. M., & Correll, C. U. (2012). Safety and tolerability of antipsychotic polypharmacy. Expert opinion on drug safety, 11(4), 527-542.
6. Gerretsen, P., & Pollock, B. G. (2011). Drugs with anticholinergic properties: a current perspective on use and safety. Expert opinion on drug safety, 10(5), 751-765.
7. Johnson, K. E., Bailey, C. E., Weiss, N. R., & Eidelman, S. M. (2021). Direct support professionals' perspectives on workplace support: Underappreciated, overworked, stressed out, and stretched thin. Intellectual and Developmental Disabilities, 59(3), 204-216.
8. Khan, T. A., Hussain, S., Ikram, A., Mahmood, S., Riaz, H., Jamil, A., ... & Godman, B. (2020). Prevalence and treatment of neurological and psychiatric disorders among tertiary hospitals in Pakistan; findings and implications. Hospital Practice, 48(3), 145-160.
9. Lähteenvuo, M., & Tiihonen, J. (2021). Antipsychotic polypharmacy for the management of schizophrenia: evidence and recommendations. Drugs, 81(11), 1273-1284.
10. Maulik, M., Westaway, D., Jhamandas, J. H., & Kar, S. (2013). Role of cholesterol in APP metabolism and its significance in Alzheimer’s disease pathogenesis. Molecular neurobiology, 47(1), 37-63.
11. Mounier-Jack, S., Mayhew, S. H., & Mays, N. (2017). Integrated care: learning between high-income, and low-and middle-income country health systems. Health policy and planning, 32(suppl_4), iv6-iv12.
12. Pooe, M. T. (2021). Prevalence of mood symptoms in patients with cannabis use admitted to the acute wards at Free State psychiatry complex with schizophrenia spectrum and related disorders (Doctoral dissertation, University of the Free State).
13. Saloojee, S., Burns, J. K., & Motala, A. A. (2016). Metabolic syndrome in South African patients with severe mental illness: prevalence and associated risk factors. PloS one, 11(2), e0149209.
14. Verghese, A., Brady, E., Kapur, C. C., & Horwitz, R. I. (2011). The bedside evaluation: ritual and reason. Annals of internal medicine, 155(8), 550-553.
15. Wang, J., Jiang, F., Zhang, Y., Cotes, R. O., Yang, Y., Liu, Z., ... & Liu, H. (2021). Patterns of antipsychotic prescriptions in patients with schizophrenia in China: a national survey. Asian journal of psychiatry, 62, 102742.
16. Yuen, J. W., Kim, D. D., Procyshyn, R. M., Panenka, W. J., Honer, W. G., & Barr, A. M. (2021). A focused review of the metabolic side-effects of clozapine. Frontiers in endocrinology, 12, 609240.
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Dr.Jan Alam
Consultant Psychiatrist At Psychiatry Hospital Jutial, Gilgit.
Dr. Abdul Shakoor
SPR – PSYCHIATRY KGN Hospital Bannu
Dr.Imama Zainab Sattar
Consultant Psychiatrist At Psychiatry Hospital Jutial Gilgit
ANUM ZAHRA
MS Psychology Visiting Lecturer At Karakorum International University Gilgit
Saiqa Batool
Visiting Lecturer At Karakorum International University And Fatima Jinnah Government Girl’s Degree College Gilgit
Tahira Jabeen
Lecturer: Hazara University Mansehra
Ayat Ul Haq
Psychologist And Counsellor Working At Psychiatry Hospital Jutial Gilgit
