Special Section on Implications of CATIE: Who Are the New Users of Antipsychotic Medications?

Abstract

507 Second-generation antipsychotics have diffused rapidly among antipsychotic medication users and have generally been regarded as a first-line treatment for schizophrenia (1–4). Additional indications by the Food and Drug Administration (FDA) for use in bipolar disorder have increased the rate of antipsychotic use, as have significant levels of off-label use and use among youths (5–8). Antipsychotics have greater off-label use than many other therapeutic classes, and these uses may not be well supported by scientific evidence (9). Although spending on psychotropic medications is increasing at a higher annual rate than is spending on other medications (17.1% versus 12.1%) (10,11), psychotropic drugs may still be underused in mental health care (12) because of barriers to treatment, such as cost and stigma. Increases in antipsychotic medication use are justifiable if the population with conditions appropriately treated with antipsychotics, such as schizophrenia and bipolar disorder, are undertreated and if antipsychotic medication treatment is cost-effective (13) compared with other alternatives. This implies that second-generation antipsychotics may not have to “pay for themselves” in terms of providing an offset in lower total health care costs (14), but they should provide greater benefits per dollar spent than older, less expensive antipsychotics or other treatments. Although there is significant variation in the benefit from drug products across individuals (15), in theory, drugs that provide greater value should diffuse much more quickly than other drugs. However, this is not always the case. Treatment decisions are made under a veil of uncertainty and market imperfections, and they are subject to a host of influences on prescribers: prescribers are never sure a priori which products will work best for any individual, and information on side effects is often recognized over time (as has been the case with significant product withdrawals, such as Vioxx). Diffusion of specific medications into treatment can be improved with a larger evidence base (16) on which to examine whether the growth of particular products is indeed rational. The Clinical Antipsychotic Trials of Who Are the New Users of Antipsychotic Medications?