Systematic review and meta-analysis finds 50% prevalence of antipsychotic polypharmacy in MENAT/EMRO countries

Antipsychotic monotherapy is considered the standard for schizophrenia treatment. However, many patients with schizophrenia and other psychotic disorders receive antipsychotic polypharmacy (APP). This can be associated with increased adverse effects, drug interactions, and treatment costs. This review aims to synthesize evidence on the prevalence of APP in the Middle East, North Africa, Turkey, and the Eastern Mediterranean (MENAT/EMRO) countries. Eight databases were systematically searched for studies published up to February 2026 that reported APP prevalence among patients with schizophrenia and psychotic disorders in MENAT and EMRO countries. The methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist, while the overall certainty of evidence was evaluated using GRADE conceptual approach (Grading of Recommendations Assessment, Development and Evaluation). The pooled prevalence was estimated using random-effects meta-analysis, and statistical heterogeneity was assessed using tau-squared (τ²) and I² statistic. Potential sources of heterogeneity were explored through subgroup and meta-regression analyses, and publication bias was assessed using funnel plots and Egger’s tests. Seventeen studies with 6,053 individuals with schizophrenia and other psychotic disorders were included. The pooled prevalence of APP was 50% (95% CI: 37%–62%), with substantial heterogeneity (I² = 98.4%), and was commonly associated with second-generation antipsychotics. Evidence linking APP to specific demographic and clinical variables was limited to a few studies, which found APP associated with higher number of hospitalizations. A pooled prevalence across nine of the APP studies revealed that only 12% (95% CI: 8% to 18%) were receiving clozapine. APP is highly prevalent in MENAT/EMRO countries. Given the potential harms of polypharmacy and the limited evidence supporting it, we recommend efforts to reduce APP and increase clozapine utilization among eligible patients. Evidence-based guidelines, clinician training, and improved clozapine accessibility are crucial to optimizing schizophrenia management in the region.