For years, the latest generation of psychiatric medications for schizophrenics, commonly known as atypical antipsychotics and hailed by some as miracle drugs, has been prescribed based on the drugs' performance in weeks-long clinical trials. A landmark study published Thursday, Sept. 22, in the New England Journal of Medicine, however, shows how these same medications performed over 18 months in the real worlds of 1,400 schizophrenics. The study's general conclusion: Atypicals are unremarkable.
Led by Jeffrey Lieberman of Columbia University, the study found that atypicals such as Zyprexa, Risperdal, Geodon, and Seroquel were about as effective as an older antipsychotic, Trilafon, in treating symptoms of schizophrenia. That's significant, because the newer drugs are vastly more expensive. Zyprexa costs about 15 times as much as Trilafon, according to drugstore.com. So there's a $10 billion-a-year business in these newer drugs for pharmaceutical companies, which have aggressively marketed them as being more effective than older ones and as having fewer side effects. On the contrary, the Lieberman study found that 74 percent of the patients stopped taking the meds because of intolerable side effects such as weight gain.
Few in mental-health circles in the Seattle area are ready to toss aside the atypicals, however. "I'm not sure how much news this is," says Peter Roy-Byrne, chief of psychiatry at Harborview Medical Center, referring to the clinical findings. "The study just doesn't show much difference between the drugs." He says that patients discontinuing medications is a longtime problem in psychiatry, as it is in much of medicine, so that's not necessarily a revelation. But says Sharon Farmer, medical director of the King County Division of Mental Health, Chemical Abuse, and Dependency Services: "The most striking thing is just the large number of people who were unhappy with their meds. If anything, it just cries out for more and better meds."
Where push may come to shove, however, is with the state, which spends $100 million a year on antipsychotics for low-income patients on Medicaid, according to Jeff Thompson, chief medical officer of the Department of Social and Health Services' Medical Assistance Administration. About 90 percent of that cost is for 45,000 patients taking the atypical medications, Thompson says.
Couldn't the state simply push some patients over to the older drugs and save tens of millions of dollars? Thompson says his department is in the early stages of reviewing the use of atypicals, although it is doing so with an eye toward understanding why some patients end up on multiple antipsychotics and not to explore reducing costs.
Even if the state and insurance companies went the route of refusing to pay for atypicals because of their high cost, they'd likely run into a rebellion among doctors and patients. If there is one thing the atypicals do well, it's that they treat schizophrenia without the side effects of twitching and cognitive impairment for which older meds like Trilafon and Haldol are notorious, according to medical experts.
Mental-health advocates also point to the fact that the study reinforces that not all meds work for all people. "What a lot of consumers [patients] and families find is they have to try two or three drugs before they hit on a treatment that works for them," says Cynthia Folcarelli, executive vice president of the National Mental Health Association.