August 15, 2009
9am. 1pm. 5pm. 9pm. And sometimes between those times. Usually the psych meds are only given in the morning and evening, unless there are anxiolytics involved (anti-anxiety medications e.g. Ativan, Klonopin, Xanax, Valium), then the physical medications are given throughout the day. The medications are scheduled like this because the psych meds have lots of side effects that can slow you down during the day e.g. drowsiness, dizziness, restlessness, agitation, etc.), so sometimes it is better to take them at night.
I kind of played a trick on you. I’m actually going to talk about medication effectiveness and cost. It is a huge deal with antipsychotics because some of the newer ones (“atypical” or “2nd generation” antipsychotics) can be extremely expensive. We’re talking about thousands of dollars a month. And any of you who pay taxes are footing the bill for them through Medicaid, which pays for about 75% of the antipsychotics used to treat people with psychosis in the U.S. This frustrates me to no end, and not because I am mad about helping people stay sane, but because the pharmaceutical companies know they get their money from the government, and yet, they charge exorbitant amounts for their drugs. The amount of money this comes out to every year: $10, 000, 000, 000. Amount paid for by taxes via Medicaid: $7, 500, 000, 000.
The argument for many years has been that the second generation antipsychotics, though more expensive, cause fewer medical problems for the patients so the overall cost is reduced. If it is true that the 2nd gen drugs cause fewer medical issues and do in fact reduce the symptoms of the mental illness, then it can be said that the patients are experiencing a higher quality of life. Fantastic! Only, that’s not how it works out.
The National Institute of Mental Health (NIMH) put up some major funding for a research project called Clinical Antipsychotic Trials of Intervention Effectiveness, affectionately called CATIE. The investigation pitted four 2nd gen antipsychotics (generic names: olanzapine, risperidone, quetiapine, ziprasidone; trade names: zyprexa, risperdal, seroquel, geodon respectively) against a 1st gen (generic name: perphenazine; trade name: trilafon). Following about 1500 patients over 18 months of treatment this is probably the most extensive antipsychotic test put out. Even though this research may have cost a million dollars to conduct, if the results favor a cheaper drug and psychiatrists’ prescribing habits can thus be changed, think of how much it could save tax payers and the government.
The reason that such and extensive study was needed is that drug companies like to fund and publish only data that supports their chemical. It’s bad advertising to put out a study that points out that your drug is less effective and causes more side effects than the other drug company’s drug. Many of the studies that are published have issues with validity. That is, they should not be applied to the patient population because of major flaws in how the study was conducted such as measuring effectiveness simply by levels of symptom management rather than quality of life, or measuring cost effectiveness only by taking into account direct health care costs to the patient, when leaving cost to the family out (family’s ability to work and play i.e. earn and spend, due to patients illness). Sadly, the complete truth is not always what you get out of the studies, so an impartial party (or economically cheap party, in this case), needs to step in and do the comparisons.
The results were unsurprising to me. Perphenazine was consistently cheaper than all of the 2nd gen antipsychotics, by about $200-$300 a month. Over time, the difference between perphenazine and the 2nd gens did close, but it still remained significantly lower. And the reason the costs closed in near one another is because people with schizophrenia generally discontinue taking their medications after some time (after about 18 months, you can count on 70% of a given population of people with schizophrenia discontinuing their medications due to a delusion or believing they are healthy now). In the case of this study, those people taking perphenazine were then switched to a 2nd gen medication, but were kept track of as the “perphenazine group.” In the end, the total amount saved by the perphenazine group was about $300-$600 per person. The great part: along with olanzapine, perphenazine outperformed all the other 2nd gen medications and olanzapine is going to go generic any time now, which means the other highly effective drug is going to be cheap too. The one benefit that olanzapine had was that people were likely to stay on it longer than perphenazine (9.2 months compared to 5.6 months).
The problem with olanzapine is that the weight gain issue is well . . . huge. I know residents that came into Andrew Residence at 150 lbs and are now weighing in somewhere around 300 lbs. Because of this they are also either shooting insulin frequently, or taking metformin (trade name: glucophage), which is a non-insulin dependent diabetes mellitus (NIDDM) drug. It turns out that a metformin prescription may help control weight gain if it is prescribed right with the antipsychotic though, which is what I plan on researching next.
Polsky, D., Doshi, J.A., Bauer, M.S., & Glick, H.A. (2006). Clinical trial-based cost-effectiveness analyses of antipsychotic use. American Journal of Psychiatry, 163, 2047-2056.
Rosenheck, R.A., Leslie, D.L., Sindelar, J., Miller, E.A., Lin, H., Stroup, T.S., McEvoy, J., Davis, S.M., Keefe, R.S.E., Swartz, M., Perkins, D.O., Hsaio, J.K., & Lieberman, J. (2006). Cost-effectiveness of second-generation antipsychotics and perphenazine in a randomized trial of treatment for chronic schizophrenia. American Journal of Psychiatry, 163, 2080-2089.