Shanghai Archives of Psychiatry, 2015, Vol. 27, No. 6
• 371 •
•Forum•
Decreasing antipsychotic polypharmacy
‘Less is more’ in the Chinese context Yifeng XU
Summary: Excessive polypharmacy is a common problem around the world, particularly in the treatment of psychiatric disorders. In mainland China use of out-of-date treatment strategies by psychiatric professionals is one of the reasons; others include unrealistically high expectations about the effectiveness of medications, the dominant role of the doctor in doctor-patient negotiations about treatment, the practice of polypharmacy in Traditional Chinese Medicine (TCM), the profit-driven nature of medical institutions and individuals, the infiltration of pharmaceutical marketing, and a critical lack of relevant research. This commentary considers the cultural factors that need to be addressed when trying to reduce polypharmacy in psychiatry in China. Keywords: polypharmacy; doctor-patient relationship; TCM; pharmaceutical companies; clinical guidelines; China [Shanghai Arch Psychiatry. 2015; 27(6): 371-373. Epub 2015 Nov 10. doi: http://dx.doi.org/10.11919/ j.issn.1002-0829.215106]
Polypharmacy is a prominent phenomenon in global medical practice that is particularly problematic in psychiatric practice.[1-2] Polypharmacy increases the prevalence and severity of adverse drug reactions and the cost of treatment. According to Healthy People 2020, polypharmacy among American elderly is the most important factor affecting the safety of pharmacological treatments in the elderly.[3] Polypharmacy has multiple definitions, including (a) the simultaneous use of excessive medication; (b) the improper use of multiple medications; (c) the use of abnormal combinations of medications; and (d) having to use medications to treat the adverse reactions of other medications. [4] Apart from psychiatrists’ inadequate understanding of pharmacokinetics and pharmacodynamics of commonly used psychiatric medications, other factors that influence polypharmacy in psychiatric practice in mainland China include: 1) Unrealistic expectations about the effectiveness and rapidity of effect of psychiatric medications. Chinese patients generally believe in the effectiveness of medication, intravenous treatment, and other intrusive medical procedures – an approach that is reflected in the extremely high usage of antibiotics. However, patients and their family members in China are often unwilling to wait for the gradual improvements afforded by most
medications used in psychiatry, particularly if the treating psychiatrist has not prepared them for the slow onset of treatment effects.[5] Clinicians’ desire to meet these unrealistic expectations of their patients often induces psychiatrists to resort to polypharmacy in an often unsuccessful attempt to speed-up the onset of clinical improvement. 2) Psychiatrists’ dominant position in the doctorpatient negotiations about treatment. The lack of knowledge of patients and their family members about psychiatric medications leaves the psychiatrist in control of the negotiations about treatment, particularly when discussing the simultaneous use of multiple psychiatric medications. Many mental illnesses are chronic, requiring ongoing pharmacological treatment and frequent interaction with mental health professionals. The use of polypharmacy can be an unintended (or intended) method of increasing the power of the psychiatrist in the long-lasting relationship between the psychiatrist and his or her patients. 3) Frequent use of multiple-component prescriptions in Traditional Chinese Medicine (TCM). Use of a single medication is uncommon in traditional Chinese medical practice. Following the TCM prescribing principles of ‘Monarch’, ‘Minister’,
Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine correspondence: [email protected] A full-text Chinese translation of this article will be available at http://dx.doi.org/10.11919/j.issn.1002-0829.215106 on December 25, 2015.
• 372 •
Shanghai Archives of Psychiatry, 2015, Vol. 27, No. 6
‘Assistant’, and ‘Guide’ ( 君臣佐使 ), a TCM prescription is typically composed of at least four different kinds of medicinal materials.[6] Despite the lack of empirical evidence of effectiveness,[7] there is wide cultural acceptance of the use of compound preparations in medical practice among both clinicians and their patients. Approximately ten percent of the 20,000 psychiatrists working in mainland China were trained in TCM medical schools and the remaining ninety percent received training in TCM as part of their training in Western medicine medical schools. This training normalizes polypharmacy in the use of TCM medications, a practice that often influences their use of western psychiatric medications. 4) The profit-driven nature of institutions and individuals. Although there are some psychiatrists working in first-class tertiary-level hospitals in large cities earning good salaries, overall remuneration for Chinese psychiatrists is relatively low both when compared to other medical professionals in China and particularly when compared with the reimbursement of physicians in high-income countries. In this setting, commercial bribery by under-regulated pharmaceutical companies (which pay psychiatrists unofficial ‘red packets’ for prescribing their medications) remains a widespread problem. [8] Moreover, the official bonuses of psychiatrists (like that of most other physicians in China) is often linked to the profit on the ward or clinic where they work, which is heavily influenced by the volume of medications prescribed. The more drugs prescribed the higher the legal and illegal bonuses, so it is not surprising that there is a tendency to promote polypharmacy. Restrictions on government-run hospitals (the vast majority of psychiatric hospitals are state-owned) on the permissible size of the mark-up (over cost) of medications is 15% while that of other types of services is only 10%,[9,10] so there is little incentive for hospitals to reduce the common practice of polypharmacy of their physicians. 5) Professionals’ doubts about clinical guidelines for the use of medications. A considerable proportion of the two million Chinese doctors only have 3 years of college education (or less). They usually do not receive or understand the latest literature
published in English or other non-Chinese languages. Moreover, most continuing medical education (CME) courses are run or funded by pharmaceutical companies because professional societies and governmental departments do not have the funds needed to provide ongoing postgraduate training to update the skills of physicians. When doctors walk into experts’ training sessions in conference venues filled with logos, hanging banners, product descriptions, free food, and other gifts, it is quite likely that they will not be attentive to the content of the speakers’ talks. Another problem is that given the relative lack of Chinaspecific evidence-based research on psychiatric medications, several clinical guidelines and manuals are filled with translated content from western materials (often adapted without permission) that may or may not be appropriate in the Chinese setting. This problem is most acute in psychiatry because of its relatively slow development compared to that of other medical specialties in China. It is not particularly surprising that most Chinese clinicians disregard the recommendations of widely promulgated clinical guidelines (which typically recommend against polypharmacy). In summary, addressing the serious issue of polypharmacy in psychiatry in China requires more than theoretical discussions of the psychopharmacological effects of the combined use of multiple drugs. There needs to be high-quality clinical research in China about these common combination treatments and the results of this research need to be converted into policies that will limit the use of polypharmacy regimens that are not proven to be more effective or safer than monotherapy.
Funding The preparation of this manuscript was not supported by any funding agency. Conflict of interest statement The author reports no conflict of interest related to this manuscript.
在中国语境中的“物稀为贵” 徐一峰
概述：过度的多重药物使用是全球性的突出现象，在 精神障碍治疗领域尤为严重。精神科专业人员对治疗 策略的知识更新不足是原因之一；其它原因还包括对 药物疗效不切实际的过高期望、医患关系中医生的主 导作用、中医学中的多重用药、医疗机构和个人的逐 利性、医药营销的强渗透力以及相关研究的严重缺乏。 本篇评论讨论了在尽力减少国内精神病学领域中的多
重用药时所需要解决的文化因素。
关键词：多重用药；医患关系；中医学；制药公司； 临床指南；中国 本文全文中文版从 2015 年 12 月 25 日起在 http://dx.doi.org/10.11919/ j.issn.1002-0829.215106 可供免费阅览下载
Shanghai Archives of Psychiatry, 2015, Vol. 27, No. 6
• 373 •
References 1.
2.
3.
4.
5.
Gallego JA, Bonetti J, Zhang J, Kane JM, Correll CU. Prevalence and correlates of antipsychotic polypharmacy: a systematic review and meta-regression of global and regional trends from the 1970s to 2009. Schizophr Res. 2012; 138(1): 18-28. doi: http://dx.doi.org/10.1016/ j.schres.2012.03.018 Xiang YT, Ungvari GS, Correll CU, Chiu HF, Shinfuku N. Trends in the access to and the use of antipsychotic medications and psychotropic co-treatments in Asian patients with schizophrenia. Epidemiol Psychiatr Sci. 2015; 20: 1-9. PMID: 26289066 Centers for Disease Control and Prevention [Internet]. Healthy People 2020. [updated October 14, 2011; cited October 14, 2011]. Available from : http://www.cdc.gov/ nchs/healthy_people/hp2020.htm The Center for Disease Control and Prevention [Internet]. Medication Safety. [updated June 13, 2014 ; cited October 2, 2015 ]. Available from : http://www.cdc.gov/ medicationsafety/ Peeters B, Van Tongelen I, Duran Z, Yüksel G, Mehuys E, Willems S, et al. Understanding medication adherence among patients of Turkish descent with type 2 diabetes: a qualitative study. Ethn Health. 2015; 20(1): 87-105. doi: http://dx.doi.org/10.1080/13557858.2014.890174
6.
Zhou MX. [The analysis of prescription pattern type of ancient physicians]. Xinjiang Zhong Yi Xue. 2008; 26(5): 1-5. Chinese
7.
Che CT, Wang ZJ, Chow MS, Lam CW. Herb-herb combination for therapeutic enhancement and advancement: theory, practice and future perspectives. Molecules. 2013; 18(5): 5125-5141. doi: http://dx.doi.org/10.3390/ molecules18055125
8.
Woodhead M. How much does the average Chinese doctor earn[Internet]? China Medical News [updated 2014 Mar 31]. Available from: http://www.chinesemedicalnews. com/2014/03/how-much-does-average-chinese-doctor.html
9.
National Development and Reform Commission, People’s Republic of China. [Notice of the Opinion on Further Consolidation of Medicines and Medical Service Market Price, the NDRC Price] [2006] No. 912]. 2006 [cited 2015 Oct]. Available from: http://www.sdpc.gov.cn/fzgggz/jggl/ zcfg/200606/t20060602_71751.html. Chinese
10. Jin CL, Chen ZL, He LM, Zhao L, Jing LM. [Study about the implementation of zero profit and related compensation policy in medical institutions in Shanghai]. Zhongguo Wei Sheng Zhen Ce Yan Jiu. 2010; 3(10): 23-28. Chinese
(received, 2015-10-07; accepted, 2015-10-22)
Professor Yifeng Xu is President of the Shanghai Mental Health Center at the Shanghai Jiaotong University School of Medicine. He is also the director of WHO/Shanghai Mental Health Research and Training Colloboration Center. His main research interests are severe mental disorders, especially biological and sociomedical research in schizophrenia and depression.
• 371 •
•Forum•
Decreasing antipsychotic polypharmacy
‘Less is more’ in the Chinese context Yifeng XU
Summary: Excessive polypharmacy is a common problem around the world, particularly in the treatment of psychiatric disorders. In mainland China use of out-of-date treatment strategies by psychiatric professionals is one of the reasons; others include unrealistically high expectations about the effectiveness of medications, the dominant role of the doctor in doctor-patient negotiations about treatment, the practice of polypharmacy in Traditional Chinese Medicine (TCM), the profit-driven nature of medical institutions and individuals, the infiltration of pharmaceutical marketing, and a critical lack of relevant research. This commentary considers the cultural factors that need to be addressed when trying to reduce polypharmacy in psychiatry in China. Keywords: polypharmacy; doctor-patient relationship; TCM; pharmaceutical companies; clinical guidelines; China [Shanghai Arch Psychiatry. 2015; 27(6): 371-373. Epub 2015 Nov 10. doi: http://dx.doi.org/10.11919/ j.issn.1002-0829.215106]
Polypharmacy is a prominent phenomenon in global medical practice that is particularly problematic in psychiatric practice.[1-2] Polypharmacy increases the prevalence and severity of adverse drug reactions and the cost of treatment. According to Healthy People 2020, polypharmacy among American elderly is the most important factor affecting the safety of pharmacological treatments in the elderly.[3] Polypharmacy has multiple definitions, including (a) the simultaneous use of excessive medication; (b) the improper use of multiple medications; (c) the use of abnormal combinations of medications; and (d) having to use medications to treat the adverse reactions of other medications. [4] Apart from psychiatrists’ inadequate understanding of pharmacokinetics and pharmacodynamics of commonly used psychiatric medications, other factors that influence polypharmacy in psychiatric practice in mainland China include: 1) Unrealistic expectations about the effectiveness and rapidity of effect of psychiatric medications. Chinese patients generally believe in the effectiveness of medication, intravenous treatment, and other intrusive medical procedures – an approach that is reflected in the extremely high usage of antibiotics. However, patients and their family members in China are often unwilling to wait for the gradual improvements afforded by most
medications used in psychiatry, particularly if the treating psychiatrist has not prepared them for the slow onset of treatment effects.[5] Clinicians’ desire to meet these unrealistic expectations of their patients often induces psychiatrists to resort to polypharmacy in an often unsuccessful attempt to speed-up the onset of clinical improvement. 2) Psychiatrists’ dominant position in the doctorpatient negotiations about treatment. The lack of knowledge of patients and their family members about psychiatric medications leaves the psychiatrist in control of the negotiations about treatment, particularly when discussing the simultaneous use of multiple psychiatric medications. Many mental illnesses are chronic, requiring ongoing pharmacological treatment and frequent interaction with mental health professionals. The use of polypharmacy can be an unintended (or intended) method of increasing the power of the psychiatrist in the long-lasting relationship between the psychiatrist and his or her patients. 3) Frequent use of multiple-component prescriptions in Traditional Chinese Medicine (TCM). Use of a single medication is uncommon in traditional Chinese medical practice. Following the TCM prescribing principles of ‘Monarch’, ‘Minister’,
Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine correspondence: [email protected] A full-text Chinese translation of this article will be available at http://dx.doi.org/10.11919/j.issn.1002-0829.215106 on December 25, 2015.
• 372 •
Shanghai Archives of Psychiatry, 2015, Vol. 27, No. 6
‘Assistant’, and ‘Guide’ ( 君臣佐使 ), a TCM prescription is typically composed of at least four different kinds of medicinal materials.[6] Despite the lack of empirical evidence of effectiveness,[7] there is wide cultural acceptance of the use of compound preparations in medical practice among both clinicians and their patients. Approximately ten percent of the 20,000 psychiatrists working in mainland China were trained in TCM medical schools and the remaining ninety percent received training in TCM as part of their training in Western medicine medical schools. This training normalizes polypharmacy in the use of TCM medications, a practice that often influences their use of western psychiatric medications. 4) The profit-driven nature of institutions and individuals. Although there are some psychiatrists working in first-class tertiary-level hospitals in large cities earning good salaries, overall remuneration for Chinese psychiatrists is relatively low both when compared to other medical professionals in China and particularly when compared with the reimbursement of physicians in high-income countries. In this setting, commercial bribery by under-regulated pharmaceutical companies (which pay psychiatrists unofficial ‘red packets’ for prescribing their medications) remains a widespread problem. [8] Moreover, the official bonuses of psychiatrists (like that of most other physicians in China) is often linked to the profit on the ward or clinic where they work, which is heavily influenced by the volume of medications prescribed. The more drugs prescribed the higher the legal and illegal bonuses, so it is not surprising that there is a tendency to promote polypharmacy. Restrictions on government-run hospitals (the vast majority of psychiatric hospitals are state-owned) on the permissible size of the mark-up (over cost) of medications is 15% while that of other types of services is only 10%,[9,10] so there is little incentive for hospitals to reduce the common practice of polypharmacy of their physicians. 5) Professionals’ doubts about clinical guidelines for the use of medications. A considerable proportion of the two million Chinese doctors only have 3 years of college education (or less). They usually do not receive or understand the latest literature
published in English or other non-Chinese languages. Moreover, most continuing medical education (CME) courses are run or funded by pharmaceutical companies because professional societies and governmental departments do not have the funds needed to provide ongoing postgraduate training to update the skills of physicians. When doctors walk into experts’ training sessions in conference venues filled with logos, hanging banners, product descriptions, free food, and other gifts, it is quite likely that they will not be attentive to the content of the speakers’ talks. Another problem is that given the relative lack of Chinaspecific evidence-based research on psychiatric medications, several clinical guidelines and manuals are filled with translated content from western materials (often adapted without permission) that may or may not be appropriate in the Chinese setting. This problem is most acute in psychiatry because of its relatively slow development compared to that of other medical specialties in China. It is not particularly surprising that most Chinese clinicians disregard the recommendations of widely promulgated clinical guidelines (which typically recommend against polypharmacy). In summary, addressing the serious issue of polypharmacy in psychiatry in China requires more than theoretical discussions of the psychopharmacological effects of the combined use of multiple drugs. There needs to be high-quality clinical research in China about these common combination treatments and the results of this research need to be converted into policies that will limit the use of polypharmacy regimens that are not proven to be more effective or safer than monotherapy.
Funding The preparation of this manuscript was not supported by any funding agency. Conflict of interest statement The author reports no conflict of interest related to this manuscript.
在中国语境中的“物稀为贵” 徐一峰
概述：过度的多重药物使用是全球性的突出现象，在 精神障碍治疗领域尤为严重。精神科专业人员对治疗 策略的知识更新不足是原因之一；其它原因还包括对 药物疗效不切实际的过高期望、医患关系中医生的主 导作用、中医学中的多重用药、医疗机构和个人的逐 利性、医药营销的强渗透力以及相关研究的严重缺乏。 本篇评论讨论了在尽力减少国内精神病学领域中的多
重用药时所需要解决的文化因素。
关键词：多重用药；医患关系；中医学；制药公司； 临床指南；中国 本文全文中文版从 2015 年 12 月 25 日起在 http://dx.doi.org/10.11919/ j.issn.1002-0829.215106 可供免费阅览下载
Shanghai Archives of Psychiatry, 2015, Vol. 27, No. 6
• 373 •
References 1.
2.
3.
4.
5.
Gallego JA, Bonetti J, Zhang J, Kane JM, Correll CU. Prevalence and correlates of antipsychotic polypharmacy: a systematic review and meta-regression of global and regional trends from the 1970s to 2009. Schizophr Res. 2012; 138(1): 18-28. doi: http://dx.doi.org/10.1016/ j.schres.2012.03.018 Xiang YT, Ungvari GS, Correll CU, Chiu HF, Shinfuku N. Trends in the access to and the use of antipsychotic medications and psychotropic co-treatments in Asian patients with schizophrenia. Epidemiol Psychiatr Sci. 2015; 20: 1-9. PMID: 26289066 Centers for Disease Control and Prevention [Internet]. Healthy People 2020. [updated October 14, 2011; cited October 14, 2011]. Available from : http://www.cdc.gov/ nchs/healthy_people/hp2020.htm The Center for Disease Control and Prevention [Internet]. Medication Safety. [updated June 13, 2014 ; cited October 2, 2015 ]. Available from : http://www.cdc.gov/ medicationsafety/ Peeters B, Van Tongelen I, Duran Z, Yüksel G, Mehuys E, Willems S, et al. Understanding medication adherence among patients of Turkish descent with type 2 diabetes: a qualitative study. Ethn Health. 2015; 20(1): 87-105. doi: http://dx.doi.org/10.1080/13557858.2014.890174
6.
Zhou MX. [The analysis of prescription pattern type of ancient physicians]. Xinjiang Zhong Yi Xue. 2008; 26(5): 1-5. Chinese
7.
Che CT, Wang ZJ, Chow MS, Lam CW. Herb-herb combination for therapeutic enhancement and advancement: theory, practice and future perspectives. Molecules. 2013; 18(5): 5125-5141. doi: http://dx.doi.org/10.3390/ molecules18055125
8.
Woodhead M. How much does the average Chinese doctor earn[Internet]? China Medical News [updated 2014 Mar 31]. Available from: http://www.chinesemedicalnews. com/2014/03/how-much-does-average-chinese-doctor.html
9.
National Development and Reform Commission, People’s Republic of China. [Notice of the Opinion on Further Consolidation of Medicines and Medical Service Market Price, the NDRC Price] [2006] No. 912]. 2006 [cited 2015 Oct]. Available from: http://www.sdpc.gov.cn/fzgggz/jggl/ zcfg/200606/t20060602_71751.html. Chinese
10. Jin CL, Chen ZL, He LM, Zhao L, Jing LM. [Study about the implementation of zero profit and related compensation policy in medical institutions in Shanghai]. Zhongguo Wei Sheng Zhen Ce Yan Jiu. 2010; 3(10): 23-28. Chinese
(received, 2015-10-07; accepted, 2015-10-22)
Professor Yifeng Xu is President of the Shanghai Mental Health Center at the Shanghai Jiaotong University School of Medicine. He is also the director of WHO/Shanghai Mental Health Research and Training Colloboration Center. His main research interests are severe mental disorders, especially biological and sociomedical research in schizophrenia and depression.
