Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

The 1980s and 1990s were a period of rapid development of new drug treatments for mental illness, including selective serotonin reuptake inhibitors (SSRIs) for depression and anxiety, atypical antipsychotics for schizophrenia and other psychoses, and new anticonvulsant medications indicated for bipolar disorder. For many patients, the new classes of medications represent advances over existing treatments with respect to efficacy, side effects or both. [1]

The new drugs are also generally easier for physicians (both psychiatrists and primary care physicians) to administer and simpler for patients to take.[2] These factors have brought about what some consider "revolutionary" changes in the treatment of mental illness.[3] However, the diffusion of these medications has been accompanied by explosive increases in psychotropic expenditures. From 1996 to 2001, psychotropic spending increased almost 20% a year, relative to 13.1% for drug spending overall, and the U.S. spent over $14 billion on psychotropics in 2001. [4] State Medicaid programs have been hit particularly hard by psychotropic spending increases. For example, Medicaid and other non-Medicare public spending on atypical antipsychotics grew at an annualized rate of 92% from 1996 to 2001.[5] In response to rapidly-rising expenditures, private plans and Medicaid programs have adopted a variety of cost containment and utilization management strategies, including increased copayments, tiered formularies, prior authorization, step therapy (i.e., requiring enrollees to try a lower-cost medication first before they can obtain coverage for a higher-cost medication), limits on prescription drug coverage, and mandatory generic substitution policies, to try to curb the growth in expenditures and influence utilization patterns for these medications. This session presents new research on several factors that influence the diffusion of new psychiatric medications, including patient demographic and clinical characteristics; physician social networks and practice arrangements; pharmaceutical utilization management tools, such as prior authorization; and pharmacy benefit limits