This measure evaluates the proportion of inpatients discharged on two or more antipsychotic medications without a clinically adequate rationale in the discharge summary. Research studies have found that 5-18% of outpatients and 50% of inpatients treated with an antipsychotic medication concurrently receives two or more antipsychotics (Stahl, Grady, 2004). Studies have also found that, compared to treatment with a single antipsychotic agent, use of multiple antipsychotics for schizophrenia or other major psychiatric disorders is generally associated with more severe side effects and generally not associated with better clinical outcomes (Ananth, Gunatilake, 2004). There are exceptions to practice guidelines recommending monotherapy, which are reflected in this measure. First, some patients who have failed multiple, adequate trials of monotherapy may benefit from addition of a second agent (Learner, et. al., 2000). Second, in an era of short hospital stays, a patient may be started on a new antipsychotic medication but discharged before the prior agent can be tapered off (Ananth, Gunatilake, 2004). Thus, clinically appropriate rationales for multiple antipsychotics include: 1)the patient has failed multiple trials of monotherapy; or 2) the inpatient physician intends that one or more antipsychotics be tapered off following discharge.

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• American Psychiatric Association
• National Association of State Mental Health Program Directors (NASMHPD)
• National Association of Psychiatric Health Systems (NAPHS)

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• Stahl SM, Grady MM. A critical review of atypical antipsychotic utilization: comparing monotherapy with polypharmacy and augmentation. Curr Med Chem. Feb 2004;11(3):313-327
• Lerner V, Chudakova B, Kravets S, Polyakova I. Combined use of risperidone and olanzapine in the treatment of patients with resistant schizophrenia: a preliminary case series report. Clin Neuropharmacol. Sep-Oct 2000;23(5):284-286.
• Ananth J, Parameswaran S, Gunatilake S. Antipsychotic polypharmacy. Curr Pharm Des. 2004;10(18):2231-2238.
• Suzuki T, Uchida H, Tanaka KF, et al. Revising polypharmacy to a single antipsychotic regimen for patients with chronic schizophrenia. Int J Neuropsychopharmacol. Jun 2004;7(2):133-142.
• American Psychiatric Association: Practice Guideline for the Treatment of Patients With Schizophrenia. Washington, DC, American Psychiatric Association, 1997
• Covell NH, Jackson CT, Evans AC, et al: Antipsychotic prescribing practices in Connecticut’s public mental health system: rates of changing medications and prescribing styles. Schizophr Bull 28:17–29, 2002.
• Stahl SM: Antipsychotic polypharmacy, part 1: therapeutic option or dirty little secret? J Clin Psychiatry 60:425–426, 1999
• Weissman EM: Antipsychotic prescribing practices in the Veterans Healthcare Administration–New York metropolitan region. Schizophr Bull 28:31–42, 2002

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