Access and Utilization of New Antidepressant and Antipsychotic Medications

Chapter II. Principal Findings

As discussed in the introduction, the present study was guided by three principal questions about the status of pharmaceutical benefits for psychotherapeutic medications. We consider each of these questions in turn.

What are the formal policies and procedures implemented by health care payers that affect consumer access to and utilization of psychiatric medications? Are these policies and procedures different for psychiatric medications than for other medication classes?

The present research indicates that psychotherapeutics are covered on an equal basis with pharmaceuticals of other classes. No evidence of selective application of more restrictive utilization controls, prior authorization requirements, or restrictive formularies was found. These problems appear to have existed in the past, but the policies have been changed in recent years. A few health care payers require that a psychiatrist prescribe psychotherapeutic drugs. Usually this restriction, where it exists, applies only to antipsychotic medications.

How does the implementation of these policies and procedures affect access to and utilization of these medications?

The assertion that access to newer psychotherapeutics is impeded by the implementation of managed care policies and procedures is difficult to substantiate. The evidence from analysis of pharmaceutical claims suggests that, as a group, new generation antidepressant and antipsychotics have diffused into common use at approximately the same rate as have new generation pharmaceuticals in other classes.

However, few healthcare payers have implemented programs to pro-actively facilitate the diagnosis and treatment of mental illness. Fewer still have attempted to measure the outcomes of mental health interventions. The modest programs to support these goals may suggest that the implementation of policies and procedures acts to inhibit access to and utilization of psychotherapeutic medications by consumers who would benefit from them in a more general way. This problem is not specific to the utilization of pharmaceuticals, but reflects a general need for more efforts in providing mental health services.

Do policies, procedures, and modes of implementation (regardless of whether they differ for mental health) create barriers to adequate mental health care even if similar policies, procedures, and modes of implementation do not create similar barriers for adequate care for other conditions?

The concerns of consumers, advocates, and providers suggests that the barriers that are in place to regulate utilization of medications of all classes may be too burdensome for mental health consumers and their providers to navigate effectively. Consumers requiring mental health care may have greater difficulty than some others in asserting their needs and entitlements within complex administrative systems. However, it is possible that a number of other consumer populations with long-term, debilitating conditions would find utilization controls imposed by health care payers difficult to navigate as well. However, the degree to which the mental health services system is burdensome to its consumers has not been compared in any systematic way to the burden imposed by physical health systems on patients with other long-term debilitating conditions.

The impact of pharmaceutical utilization controls or cost-sharing requirements on mental health consumers who may have concurrent physical illnesses is likely to be more severe than it is for consumers without mental illnesses. Mental health consumers are more likely to exceed quantity limits and incur higher dollar amounts in cost-sharing than are other consumers for this reason. This may force the consumer or provider to make a choice between filling a prescription to treat the physical illness and filling a prescription to treat the mental illness. This problem is compounded because providers of mental and physical health services may not be fully aware of all concurrent medications the patient requires. The lack of coordinated care increases the potential for adverse drug interactions, even as it may increase the complexity of how to coordinate care to assure that the patient receives all necessary treatments. This problem is an interesting area for possible exploration.

A. Access to Newer Antidepreseant and Antipsychotic Medications

1. Pharmaceutical Benefits

   Pharmaceutical benefits are commonly available for psychotherapeutic agents.

   • Most health care payers interviewed covered pharmaceuticals to at least some degree.
     • Employers offer pharmaceutical benefits as part of comprehensive health insurance. Employers work with carriers to design benefits, but rarely become involved in the details of individual drug coverage.
     • Behavioral Health Managed Care Organizations rarely become involved with the administration of pharmaceutical benefits and therefore exercise only limited influence over these.
   • Psychiatric medications are usually covered as part of the general pharmaceutical benefit; rarely are these carved out from the general benefit.
   • Pharmaceutical benefits are financed by a mix of capitated and fee-for-service arrangements, although fee-for-service appears to be regaining popularity.
   • Although consumer advocacy organizations claim that psychotherapeutics are covered at a lower level than other medications, this research found no evidence to support this claim at the administrative level.

   Limits on prescription coverage and cost sharing requirements apply equally to all classes of medications.

• Consumer associations and pharmaceutical manufacturers contend that psychotherapeutics often are subject to higher copayments or lower total cost caps than are other classes of drugs.
  • Our research has not validated this concern.
  • Copayments required for branded drugs are universally higher than those required for generics. Therefore copayments required for new generation psychotherapeutics are usually higher than those required for generic medications of any class.
• None of the Medicaid programs interviewed require different cost sharing for psychiatric drugs compared to other drug classes.
  • Copayment requirements differ only by whether the drug dispensed is a branded drug or a generic drug.
  • Currently, 12 State Medicaid programs (Arkansas, California, Florida, Georgia, Mississippi, Nevada, New York, North Carolina, Oklahoma, Texas, West Virginia, Wyoming) limit the number of prescriptions per patient per month.
  • All but two States (Indiana and Iowa) place limits on the number of refills per prescription or the quantity that can be dispensed at any one time.
• Within the private sector, limits and cost-sharing requirements are applied equally to all drug classes.
  • None of the private insurers interviewed restrict the number of prescriptions reimbursed per recipient.
    • Individual plans may have annual limits on the dollar amount reimbursed. This limit applies to all pharmaceuticals and is not selectively supplied to psychotherapeutics.
  • None of the private insurers demand higher copayments for psychotherapeutic agents than they do for other drug classes.
    • Most plans require a higher copayment for branded drugs than they do for generics.
    • Several plans are moving to "three tiered copay" whereby different copayments are required for generics, drugs designated by the payer as "preferred brands", and drugs designated "non-preferred brands." The designation "preferred" and "non-preferred" is one made by the health care payer and reflects a complex (and usually proprietary) assessment of issues including efficacy, safety, therapeutic duplication, use and abuse potential, cost, and cost-effectiveness. Within several plans examined, new generation psychotherapeutics do not appear to be forced wholesale into the "non-preferred" group. Rather, the preferred group usually includes a selection of several new generation antidepressants (typically 3 or 4) and antipsychotics (typically at least 2), with the balance of the group being placed in the third tier.

Patients are not routinely forced to change medications when the transitioning between treatment settings (e.g., inpatient to outpatient) because of formulary restrictions, or when transferring among payers.

• State programs were unaware of any problems with continuity of care between treatment settings.
• State programs were unaware of any systematic differences between the pharmacy benefit coverage between Medicaid and State Mental Health programs.
  • These often work off the same formulary and route purchases through the same channels.
• The DoD and VA reported no systematic problems insuring the continuity of care between inpatient and outpatient settings.
  • The VA has established procedures to insure a patient is managed consistently when discharged from an inpatient setting.
• Private payers uniformly report that access to psychotherapeutic agents is no different between inpatient or outpatient settings.
  • Most MCOs make allowances for a new enrollee to continue treatment on non-formulary drugs started while insured by another payer.

Credentialling of prescribers is relatively rare and operates almost exclusively in the private sector.

• The issue of prescriber credentialling largely applies to antidepressants.
• Many payers are concerned about inappropriate use of antidepressants for purposes other than the treatment of depression. Restrictions on the prescription of these agents by primary care physicians are designed to avoid misuse.
• Most providers and payers agree that prescription of antipsychotics by primary care physicians is not medically appropriate.

2. Formularies

   Manufacturers, providers and consumers concur that formularies are no longer restricting access to newer psychotherapeutic agents

   • Closed formularies are maintained by 8 State Medicaid programs (California, Colorado, Hawaii, Illinois, Michigan, Montana, Ohio, and South Dakota). All HCFA(now known as CMS)-approved drugs are covered if Prior Authorization (PA) is obtained.
     • Only California appears to severely restrict the choice of pharmaceutical agents available without PA.
   • None of the State Mental Health Systems interviewed for this study exclude any of the newer antidepressant or antipsychotic medications from coverage.
   • Formularies were used by over 75% of HMOs in 1997, up from less than 50% in 1990. At the same time, physicians appear to have increasing influence over the choice of medications included on the formulary.
   • Employers do not generally get involved with the specifics of formulary management. Most of the employers interviewed stated that they had open formularies.
   • The formularies of the New York State prison system and the Navajo Region of the Indian Health Service are closed. These programs most aggressively pursue switching of patients from non-formulary to formulary drugs.

   The concept of "open, closed, or restricted" formulary is changing in meaning and is not an accurate depiction of access.

   • In 1997, 33% of plans used formularies described as "closed."
     • Often, closed formularies allow non-formulary drugs to be reimbursed if prior authorization is obtained.
   • Closed formularies are being replaced by "preferred" drug lists, whereby physicians are encouraged, but not required, to prescribe a particular drug.
     • In 1997, 52% of plans used formularies described as "selective" or "partially closed."

   Plans with closed formularies may take active steps to enforce the formulary. These may include:

   • Physician profiling;
   • Claim lockouts;
   • Withholding physician bonuses; and
   • Imposing financial penalties.

   Effectiveness and cost are the most frequently cited barriers to formulary approval. The relative importance of each of these factors depends on the class of drugs and particular interest of an individual health plan.
   • Any drug for which the manufacturer has entered into a rebate agreement with HCFA(now known as CMS) is eligible for inclusion on Medicaid formularies.
     • There are only 10 exceptions, mostly barbiturates and benzodiazepines.
     • Medi-Cal, on the other hand, has a more complex method of approving drugs for formulary inclusion. These criteria were published in a journal article describing the information needs for this purpose.⁶ In addition, Medi-Cal makes available its criteria for formulary review.
   • Private health care payers maintain pharmacy and therapeutics committees that review formularies on a regular basis. These committees are made up of physicians, pharmacists, and administrators.
   • Employers do not maintain their own P&T committees, but work with their MCOs and PBMs to design a formulary suitable to their needs.

   Newer antidepressant and antipsychotic medications have attained formulary status in most of the programs surveyed in this study.

   • Most payers cover at least two of the four SSRIs approved in the US for the treatment of depression (fluoxetine, paroxetine, citalopram, sertraline), and at least one other new antidepressant (venlafaxine, nefazadone, bupropion).
   • Most payers cover at least one of the new-generation antipsychotics.
   • The private sector has embraced the newer agents, although formularies appear to be more actively managed than in the public sector
   • The formulary status of the newer antidepressant and antipsychotic agents is consistent with the pattern observed for other classes of branded pharmaceutical agents.

3. Prior Authorization

Provider and consumer associations interviewed report that prior authorization and paperwork requirements are now the primary barrier to access.

• These groups contend that prior authorization is required more for mental health pharmaceuticals than other drugs.
• These groups also contend that paperwork requirements to obtain PA are unduly burdensome.
  • The present research suggests that PA is becoming increasingly automated and that this trend is adding efficiency to the process.

Antipsychotics no longer require prior authorization as a matter of policy. However there are some restrictions at the facility (community) level. PA may be more common for antidepressants.
• State Medicaid programs may require PA only when therapeutic "equivalents" exist.
  • HCFA(now known as CMS) has the authority to monitor and regulate the process of obtaining PA and determine whether processes are unduly burdensome.
• Prior Authorization for antipsychotics is relatively rare within the private sector.
  • PA is implemented at the request of the client to the company administering pharmaceutical benefits.
  • PA is required no more frequently for psychotherapeutics than it is for other classes of pharmaceuticals
  • The trend in private insurance appears to be towards open formularies with more active management of "lifestyle" drugs (e.g., drugs for migraine, erectile dysfunction) via utilization controls.
4. Step Care

   Traditional step care protocols, whereby patients are required to try an older generation agent prior to obtaining approval for reimbursement of a newer one, have largely disappeared.

   Currently, it is more common for payers to designate one or two preferred pharmaceuticals chosen from the newer agents. Patients must first experience a treatment failure on a preferred agent prior to being reimbursed for a non-preferred agent.

   • These practices may contribute to the perception that access is too cumbersome.
   • These practices may require switching among pharmaceutical agents within a given class (e.g., SSRIs).

B. Utilization of Antidepressant and Antipsychotic Medications

1. Treatment Guidelines and Preferred Medications

   HCFA(now known as CMS) does not instruct States on the choice of appropriate medications for use in specific illnesses. However, HCFA(now known as CMS) did request that States make atypical antipsychotics available for first-line treatment of schizophrenia if requested by physicians.

   State Medicaid and State Mental Health programs have not widely adopted treatment guidelines for depression or schizophrenia. This situation has begun to change somewhat with the advent of Medicaid Managed Care.

   • The Texas Medication Algorithm Project algorithms for schizophrenia, depression, and bipolar disorder are the outstanding examples of explicit protocols for the management of the mentally ill within public systems.

   There is no consensus on the best first line agents for the treatment of schizophrenia or depression among private payers.

   • Treatment guidelines within private sector payers are only beginning to appear for depression. Schizophrenia is not a primary concern in the private sector.
   • Several PBMs are developing treatment guidelines that recommend the use of new generation agents first-line, together with guidelines for dosing. These guidelines do not endorse one agent over another.
   • Employers do not generally concern themselves with the selection of preferred or covered pharmaceutical agents. Likewise, they do not develop or adopt treatment guidelines or disease algorithms for depression, bipolar disorder or obsessive-compulsive disorder.
   • However, health benefits consultants report that they generally encourage employers to cover the most up-to-date pharmacotherapies for mental illness.
   • Most BHMCOs are not involved in the writing of clinical practice guidelines for the treatment of mental illnesses.

2. Clinical Development and Marketing

   Manufacturers express no bias against developing a new drug for mental health indications in comparison with physical health indications.

   • However, because many persons with mental illness have public health insurance, patient recruitment and retention in trials can be a greater challenge for behavioral health than for physical health drugs.

   The MCOs and PBMs interviewed reported that traditional clinical trials are of relatively short duration and measure outcomes using instruments not readily translatable into regular clinical practice, such as standardized psychiatric rating scales.

   Manufacturers devote considerable effort to marketing psychotherapeutics to physicians and patients, although tactics vary. The extent to which marketing efforts affect sales success has not been quantified.

   Although it is generally assumed that manufacturer contracts and rebates may affect drug utilization, no data exists to support this idea, largely because such data are considered trade secrets.

3. Utilization Management

   All of the payers interviewed maintain some form of drug utilization review (DUR) program.

   • Most payers use DUR as an educational tool to encourage good prescribing practices.
   • Several payers use DUR as a monitoring tool to enforce compliance with formulary, PA and treatment guidelines.

   Monitoring of psychotropic medications occurs no differently than for other classes of pharmaceuticals and tracks duplication, overuse, under-use and possible drug interactions.

4. Provider and Patient Compliance

   Programs that monitor patients for compliance with therapy or providers for compliance with treatment guidelines are in their infancy.

   • Provider compliance is a greater priority within the private sector than the public sector.
     • Provider compliance programs generally do not operate in traditional Medicaid programs. Any willing provider (AWP) legislation generally excludes the possibility of provider credentialling.
     • State Mental Health programs do not monitor their providers for compliance with treatment or prescribing guidelines on a statewide basis. These programs often are implemented at the level of the individual hospital or community mental health center.
     • The DoD and the VA are more aggressive in monitoring provider practice patterns. Both routinely review provider records to monitor for compliance with formularies, evaluate dosing patterns, and monitor inappropriate use of medications at the treatment facility level.
     • Although most payers interviewed use formularies and treatment guidelines primarily as educational tools, several do enforce compliance. Both incentives and disincentives are used to encourage provider compliance, although these practices appear to be less common than many fear.
       • Many plans are beginning to implement comprehensive disease management programs that include a provider component.
     • PBMs generally do not enforce physician compliance with treatment guidelines or disease management programs, but encourage compliance through education and notification.
       • Maintaining patient confidentiality often precludes adequate data collection and monitoring on a case-specific basis.
     • Employers monitor providers for compliance with guidelines via concurrent or retrospective DUR. Furthermore, employers may partner with their PBMs or HMOs to conduct provider education.
   • Patient compliance and disease management programs appear to be more common in the private sector than the public sector. Compliance or disease management programs are less common for schizophrenia than they are for depression.
     • Patient confidentiality remains a barrier to the effective implementation of disease management programs. This is especially true in the public sector
     • Manufacturers focus on physician compliance rather than patient compliance due to concerns for patient confidentiality and greater ease of tracking physicians.
       • Patient compliance and disease management programs have not necessarily proven financially beneficial to manufacturers.
     • PBMs, MCOs and employers are beginning to implement case management programs for depression and to a lesser degree, schizophrenia, even though case management is often delegated to behavioral health carve-outs.
       • Programs that focus on screening and diagnosis are more common than those that actually focus on case management.
     • Employer-sponsored programs designed to assist patients in recognition and treatment of mental illness are not as common as physician-targeted programs.
       • Employers expressed reluctance to implement these programs due to patient confidentiality, the difficulty of data acquisition and the difficulty of demonstrating value of these programs.
       • Employee assistance programs (EAPs) play a primary role in the detection of mental illness, acting as triage networks and referral mechanisms.
     • Once employees are undergoing treatment for mental illness, BHO carve-outs may provide generic case management.
     • PBMs are reluctant to operate patient compliance programs due to confidentiality concerns. However, one PBM offers compliance assistance for antidepressants and will survey physicians for effectiveness.

• In 1998, 51% of the 11 million Medicaid antipsychotic prescriptions were for atypicals.
  • In contrast, atypicals accounted for 17.5% of 9.1 million Medicaid antipsychotic prescriptions in 1995.
• In 1998, 62% of the 19 million Medicaid antidepressant prescriptions were for new-generation, branded antidepressants.
  • In contrast, new generation antidepressants accounted for 44% of 13.6 million Medicaid antidepressant prescriptions in 1995.

• The growth in both number of prescriptions for and cost of antidepressants and antipsychotics outpaces that of the aggregate by more than 2-fold.

• Although the number of all prescriptions (i.e., from any therapeutic category) reimbursed by Medicaid has remained relatively constant between 1995 and 1998, expenditures have increased by over 40%.
• Prescriptions for antipsychotics grew 11% between 1995 and 1998 while expenditures increased by more than 160%.
  • Total Medicaid spending on antipsychotics exceeded $1.3 billion in 1998.
  • Uptake of atypical antipsychotics is driving pharmacy costs for this class.
• Prescriptions for antidepressants grew 40% between 1995 and 1998 while expenditures increased by approximately 96%.
  • Total Medicaid spending on antidepressants reached $985 million in 1998.
  • Increased numbers of prescriptions together with uptake of new-generation antidepressants is driving pharmacy costs for this class.

1. Utilization of Antipsychotics

   In 1998, 51% of all Medicaid prescriptions for antipsychotics were for atypical antipsychotics. Expenditures on atypicals accounted for 89% of total spending on antipsychotics.

   • In 1998, Medicaid programs in 45 States analyzed paid for nearly 11 million prescriptions for antipsychotics.
     • Phenothiazines accounted for the largest share of antipsychotic prescriptions, with approximately 3.0 million prescriptions, or a 26% share.
     • Risperidone ranked second in number of prescriptions (2.8 million, 25%).
     • Olanzapine ranked third in number of prescriptions (2.2 million, 20%).
   • These 11 million prescriptions corresponded to expenditures of $1.3 billion.
     • Olanzapine accounted for the largest share of spending for antipsychotics at $536 million (42%).
     • Risperidone ranked second at $395 million (31%).
     • Clozapine accounted for the third largest share of expenditures, $172 million (14%).
   The use of atypical antipsychotics in Medicaid has grown dramatically since 1995. Concomitantly, the use of antipsychotics as a class has grown by 20% since 1995.
   • Medicaid antipsychotic prescriptions rose from 9.2 million in 1995 to 11 million in 1998, an increase of nearly 20%.
     • It appears that the introduction of atypical antipsychotics did not merely replace older therapies, but instead expanded the market for use of these agents as a category.
       • Medicaid prescriptions for risperidone increased from just over 1 million in 1995 (12% of total) to nearly 2.8 million in 1997 (25% of total).
       • Medicaid prescriptions for olanzapine have risen from 43,000 prescriptions in 1996 (0.5%) to over 2.1 million prescriptions in 1998 (20%).
       • Prescriptions for oral haloperidol decreased from 2.1 million in 1995 (23%) to 1.6 million in 1998 (18%).
       • Prescriptions for phenothiazines decreased from 4.2 million in 1995 (47%) to just under 3 million in 1998 (27%).
     • This trend of increasing numbers of antipsychotic prescriptions may indicate that more patients are willing to use the newer agents.
     • This trend may also reflect increased use in the management of other diseases, such as the behavioral disturbances associated with dementia.

   Expenditures on antipsychotics have vastly outpaced the growth in number of prescriptions.

   • Total Medicaid prescriptions for antipsychotics increased from 9.2 million in 1995 to nearly 11 million in 1998, an increase of 20%.
   • Total expenditures increased from $484 million in 1995 to $1.3 billion in 1998, an overall increase of 160%.

   In several high-volume States (FL, IL, MA, MD, MI, PA) risperidone has become the most frequently prescribed class of antipsychotic, outpacing the national averages.

   The uptake of newer antipsychotic agents into Medicaid immediately post-launch has been rapid.

   • From launch in the 4^th quarter of 1996, olanzapine gained 8% market share within four full quarters of marketing.
     • At the end of the second full year on the market, olanzapine attained a market share of 16%.
     • The number of olanzapine prescriptions more than doubled in the second year on the market.
   • From the time of the launch of olanzapine, risperidone market share increased from 17% to 22%
     • During this same period the number of risperidone prescriptions increased nearly 50%.
   • The uptake of quetiapine has been slow relative to olanzapine.
     • This difference may largely be attributed to market timing and marketing savvy.

2. Utilization of Antidepressants

   In 1998, 62% of antidepressant prescriptions were for new-generation, branded antidepressants.

   • Medicaid programs in 45 States paid for over 19 million prescriptions for antidepressants.
     • The selective serotonin reuptake inhibitors (SSRIs) comprised 48% of total antidepressant prescriptions in 1998.
       • Prescriptions for the three leading agents (fluoxetine, paroxetine, and sertraline) were nearly equal with approximately 3 million prescriptions each, or a 15-16% share each.
     • Tricyclic antidepressants accounted for 27% of total prescriptions
     • The four other new generation antidepressants (bupropion, mirtazapine, nefazadone, and venlafaxine) together accounted for 14% of prescriptions.
   • In 1998, Medicaid expenditures on antidepressants in these 45 States reached nearly 1 billion dollars ($985 million).
     • Together, fluoxetine, sertraline and paroxetine comprised over 70% of all Medicaid spending on antidepressant drugs in 1998 ($711 million).
       • Fluoxetine accounted for 30% ($288 million) of all Medicaid spending for antidepressants in 1998.
       • Spending for sertraline reached only $214 million (23% of all Medicaid dollars reimbursed for antidepressants in 1998).
       • Dollars spent on paroxetine comprised only $199 million (20% of all Medicaid dollars spent on antidepressants in 1998).
     • TCAs accounted for only 5% of all Medicaid dollars reimbursed for antidepressants ($54 million).
     • Other new antidepressants bupropion, venlafaxine, nefazadone, and mirtazapine together accounted for expenditures of approximately $173 million or 18% of total expenditures.

   The use of new-generation antidepressants in Medicaid grew dramatically between 1995 and 1998. As with antipsychotics, the growth in use of newer antidepressants rapidly outpaced the replacement of older agents.
   • Prescriptions for antidepressants increased from 13.7 million in 1995 to 19.3 million in 1998, an increase of over 40%.
     • Sertraline prescriptions increased from just over 2 million in 1995 to just over 3 million in 1998.
     • Fluoxetine prescriptions increased from just over 2 million in 1995 to just fewer than 3 million in 1998.
     • Paroxetine prescriptions increased from 1.2 million in 1995 to 2.9 million in 1998, an increase of 130%.
     • Prescriptions for TCAs fell from 6 million prescriptions in 1995 to 5 million in 1998 -- a 20% decrease.

   Medicaid expenditures for antidepressants outpaced the rate of growth in number of prescriptions between 1995 and 1998.

   • Total expenditures increased from $500 million in 1995 to $985 million in 1998--an average increase of 25% per year, and an overall increase of 96%.
     • Much of this increase can be attributed to the steady, yet significant rise of the three leading SSRI antidepressants.
       • Expenditures for paroxetine increased nearly three-fold (an increase of $128 million over four years.
       • Expenditures for fluoxetine increased 73% ($120 million).
       • Expenditures for sertraline increased 64% ($84 million).
       • Expenditures for TCAs fell from $77 million in 1995 to $54 million in 1998.

3. Comparison of Psychotherapeutic Utilization with Utilization of Other Drug Classes

   New-generation antidepressants and antipsychotics have been accepted into common use by Medicaid programs at about the same rate and to the same extent as other innovator drugs.

   • Newer antipsychotics appear to be proportionally more expensive than other new generation pharmaceuticals such as oral antidiabetics. Newer antidepressants appear to be roughly equivalent in cost to these other classes.

D. Cost-Effectiveness of Newer Antidepressant and Antipsychotic Medications

1. Cost-Effectiveness of Newer Antidepressants

   Published cost-effectiveness literature shows no clear differences in total treatment costs associated with the use of different antidepressant agents, although individual studies have claimed that one particular agent is superior to another.

   • In numerous studies, researchers failed to find a difference in cost or effectiveness between treatment groups.
   • Several individual studies have found that treatment with newer agents is cost-saving compared to treatment with older agents
   • A few other studies have found that treatment with newer agents is cost-saving compared to treatment with older agent.
   • Modest evidence suggests that SSRIs are more cost-effective than TCAs.
   • The evidence for the cost-effectiveness of other new-generation agents such as venlafaxine and nefazadone is less convincing, but suggests similar cost-effectiveness to SSRIs.

   The clearest result from these studies is that patient compliance with the newer antidepressants is considerably better than with TCAs. For this reason, the newer antidepressants may be more cost-effective than the older antidepressants.

   These studies indicate that reliance on older generation antidepressants as preferred therapy is unlikely to realize any cost-savings if total health-systems costs are to be included. As a result the exclusion of new generation antidepressants on cost grounds cannot be justified.

2. Cost-Effectiveness of Newer Antipsychotics

   Evidence from the pharmacoeconomic literature shows that treatment using the new antipsychotics exhibits economic advantages over treatment using the older antipsychotics. This evidence for olanzapine and clozapine is superior to the corresponding evidence for risperidone.

   The results of numerous studies together provide strong evidence of clozapine's superior cost-effectiveness relative to older, typical antipsychotics in treatment resistant schizophrenia.

   The paucity of well-designed studies precludes drawing any conclusions regarding relative pharmacoeconomic differences among atypical antipsychotics.

References

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Last updated August 20, 2000