Okay, first off disclaimer: I can only speak in generalities. There may be things specific to this particular patient that cannot be addressed by me because I haven't talked to him/her in person.
I see no need to give Abilify at a BID dosage at 10mg BID. Again this is with the disclaimer that there may be something about this patient that makes them an exception to the rule.
1) Abilify pills are, for all intents and purposes, priced per pill. In effect, this doctor has doubled the price of the patient's med regimen with no reasonable medical evidence as far as I know to increase it's efficacy by giving them 10 mg QBID instead of just 20 mg QAM.
2) The manufacturer recommends once daily dosing, and the half life of the med and it's metabolites is relatively long (75 hrs for the med, 146 hours for it's metabolites) leaving no reason for me to believe that BID dosing will be better than once-daily dosing.
3) The med, per the manufacturer, because of it's partial dopamine agonism actually can cause wakefulness. Stepping aside from what the manufacturer says because sometimes what happens in real-life doesn't match the textbooks, I have found this to be the case with most patients. Some doctors I know tell their patients to take it at night then the patients don't know why they can't fall asleep. When I get the patients and tell them it's supposed to be given in the morning, all of a sudden they get upset and wonder why that doc told them to do that. I can only answer I don't know.
The manufacturer did mention that in cases where the med is given above it's guidelines (>30 mg QAM), it does cause sedation in the majority, but that's not what's going on here.
Giving it at BID dosing could lead the to the patient taking the med at night.
Again this is all with the disclaimer I mentioned. Several patients don't follow the norm, but they should not be put on a medication regimen first-line as if they don't follow the norm.
the older (40+ years of experience) is covering.
Older doesn't mean better. Trust me on this. I've see a lot of old doctors that don't know much. Several doctors turn off the light-bulb after residency. Some even turned it off during residency but were able to get away with it. The longer it's been turned off, the worse the doctor.
Now if the light-bulb's been on longer that's a different story...
In general treatment recommendations in most texts recommend to increase a dosage to the manufacturer's maximum before going on to another medication. An exception is if the patient had some benefit to one but cannot tolerate it at a dose that's lower than the manufacturer's maximum, but is still in need of more treatment.
The way most psychotropics work, you got to reach at least a particular dosage before you give up or add augmentation with another med. E.g. In Seroquel D2 blockage doesn't even start until about 150mg+ per day, you will likely not even reach any benefit until 400 mg +, and in many patients you will have to go to 800 mg (if not even more!) If you get no antipsychotic response at 100 mg Q daily it's idiotic in terms of psychopharmacology to believe that you now got to add another med. You got to increase the dosage before you give up on it as a monotherapy. With each med that dosage differs because most of them bind to other receptors before they bind to the D2 receptors, and the molecular weights of each med influence the actual mg of dosing needed.
This all leads back to what I said before, don't try another med until the maximum's been reached in one or the patient got a benefit with the med but cannot tolerate it at the maximum dosage.
There was a recent AJP article showing the using two meds could be better than one, but while that may be true, it's not true in every case (though in a significant number), and monotherapy should still be the preferred goal because it's cheaper and if it works, less side effects for the patient, and easier for compliance.
http://ajp.psychiatryonline.org/article.aspx?Volume=168&page=667&journalID=13
Do other see this sort of approach at times - throw everything at it?
Unfortunately most of the doctors that do this, more often than not, IMHO don't really know what they're doing.
A problem with making blanket assumptions is there are so many exceptions to the rule. I've had my fair share of polypharm patients, but I did follow the guidelines of only going to 2nd, 3rd, or even 4th meds only if one gave a benefit and it could not be raised higher. Most of these patients in the polypharm category were patients I had in forensic settings where the patients in general were much more treatment resistant, and far more dangerous if not on meds.
I can certainly say that some doctors I've known well enough to know they don't know squat. E.g. I know one doctor that starts every patient on about 4-8 meds the first visit. I'm not joking: an antidepressant, antipsychotic, mood stabilizer, stimulant, benzo, cogentin, and a sleep med plus a few more. Almost every single patient I've known who saw this guy thought he was terrible, and most of them were far worse with treatment with this guy than even without it.
I don't want to judge the doctor you mentionedr, but any doctor should have at least some type of sound model based on evidenced-based research or at least very good anectdotal experience as why they're doing what they're doing. Also if a doctor engages in polypharmacy, they should at least document the reasoning and benefit that occurred with each med. I've seen too many doctors throw meds around as if they're throwing splotches of paint on a canvass. It's based on an "inner feeling" and not on psychopharmacology, evidenced-based medicine, or even common sense.
E.g. I had a guy I discharged on Risperdal 4 mg QBID and Zyprexa 15 mg QHS. In short, he got no benefit from Risperdal at higher than 4 mg QBID (he was titrated up to 8 mg QBID), but was still having hallucinations at 4 mg QBID (though his paranoia and hostility were greatly reduced), and when Zyprexa was added he was very much better. I told him that I could try to shoot for monotherapy and see if the Zyprexa by itself could do the trick, but the guy was so happy that he finally was free from psychotic symptoms that he didn't want to mess with his current regimen. He opted to stay on both. Given that it took us 2 months to get him better, he understood the risks and benefits of the polypharmacy, he had the capacity to make a decision, I let him take this regimen, and I documented all of it, including summarizing it on his discharge summary. Personally I think Zyprexa may have been the best med for him and monotherapy was worth a shot, but it was his life and he has capacity, so he should've had the final decision.
