Abstract
David Horgan Melbourne, Australia:
Many clinicians in Australia practice polypharmacy, in particular combining antidepressants in patients who have failed to respond adequately to monotherapy, even supplemented by lithium or T3. Equally, many academics warn that polypharmacy is at worst medicolegally hazardous, and at best unnecessary in their experience.
It is a brief respite from feeling like an outlaw for 51 weeks of the year to attend the American Psychiatric Association Annual Conference. In contrast to the Australian official line, so to speak, prominent American psychiatrists regard polypharmacy as standard practice. While acknowledging that there are no adequate trials yet to prove the superior efficacy of such therapy in complicated or resistant depression, their view is based on a combination of clinical need and very little evidence of significant adverse effects if combinations are introduced and used cautiously.
Indeed, as was pointed out at the Conference on a number of occasions, the Practice Guidelines of the American Psychiatric Association for the treatment of depressive illness [1] recommend that failure to respond to a single antidepressant should be followed by a change of antidepressant; supplementation with lithium or T3; and combination of antidepressants.
It is obviously a matter of professional opinion as to whether combining antidepressants or leaving patients with distressing depressive symptoms and suicidal ideas poses most danger to the patients. It would, however, pose less danger to Australian psychiatrists, from a legal perspective, if they were aware that countless numbers of colleagues in other countries would regard combined antidepressants as standard practice, and would even suggest that failure to combine antidepressants in the face of persisting patient suffering is in itself exposing a psychiatrist to legal action for inadequate treatment and any consequences thereof.
Whether one is influenced by DSM-IV or ICD-10, there can be no denying the vast body of academic and clinical knowledge available overseas. What is good clinical practice in Australia cannot be defined by the unavoidably limited resources of our sparsely populated island.