You wrote: "Psych patients are in no position to force a free market for antipsychotics." You're right, but for a different reason.

Atypicals are expensive, but the solution isn't to force them to be less expensive, or price caps, etc, etc. If they truly aren't better than the older drugs, then psychiatrists simply shouldn't be prescribing them- as much- and THEREFORE the price will fall as Pharma attempts to recoup some money. (Demand becomes elastic.)

The problem is that psychiatrists prescribe these medicines (for various reasons, some good, some bad) with no mind to the cost.

But IF psychiatrists were forced to consider cost as a factor (say, a pharmacy budget per patient rather than formulary restrictions) then they would have to be more judicious about "expensive" drugs, and more attentive to the literature about their efficacy and side effects. In other words, they'd have to be more rigorous about whether a drug is worth the money.

In this scenario, Pharma will have no choice but to reduce their costs, and they will also not have the incentive to create "me too" drugs.

And simple efficacy comparisons won't be enough. For example, say Seroquel and Haldol have the same efficacy. Seroquel is more expensive then Haldol; but is Seroquel more expensive than Haldol + cogentin + ambien? etc, etc.

Price caps aren't the answer. The answer is the "free market", but in this case it means giving the doctor a budget within which he must operate.

Real life numbers from many medications that have been bought and paid for in the last year for either my daughter or myself, one month supply, based on no insurance. I am fortunate to have insurance, and my daughter has medical coupons.

Lithium Carb 300mg caps $50.43

Haldol $40.10

Zyprexa 10 mg tabs $755.04

(Look at that price on Zyprexa!)

Zyprexa 5mg tabs 253.89

Prozac 10 mg caps 25.21

Cogentin 1 mg tabs 10.68

Seroquel 25mg tabs 77.22

Xanax (brand name, not generic) 1mg XR= $122.49

One doctor has my daughter on the Haldol/10 mg Tabs combo=$845.57 per month(that does not include the prescription benedryl she was on as well.)

Another combo from another doc included Prozac/ 5 mg Zyprexa tabs/Cogentin=$289.78 per month.

One of the worst 5 medication discharges we had from another doc included trileptal, as well as 200mg tabs of Seroquel, I can't find those pharma receipts right now, but the above listings should put some of this into perspective.

My daughter currently is on Clozaril and I will be looking into the price on that one, I don't have the paperwork here. She takes Clozaril, Lithium and Cogentin right now as her primary medications. She took Zyprexa for over 6 straight years, and sometimes at higher doses.The higher the dose, the more expensive.

Looking at the list of meds I listed here, it is fairly easy to find a typical combo of meds a person may be taking and do the math.

If a person does not have insurance then what?

This is what happens to many mental health patients/consumers on low to no income: they don't get treatment, because they cannot afford their medications.

To know if a medicated population is doing well, it is imperative to get every one equal access to medications. Otherwise all the studies in the world can never have adequate numbers to back up their claims of efficacy.

Note that the least expensive medications were given to my daughter at county facilities. Zyprexa , one of the most expensive antipsychotics was given to her in the State Hospital. All of the agencies have contracts for medications, and you will often see patients come out of an institution on over-priced meds such as Zyprexa, only to be tossed into the low-income support services in this state at least, and then not be able to afford those medications.
Patients then, give up, stop taking the medications, and it becomes an often revolving door status in and out of hospitals.
Continuity of care outpatient is key. The pharma companies do not have that in their list for bottom lines.
Add in private care psychiatrists that we all know do not have low co-pays, due to insurance lacking parity, and we have one hell of a mess.

Now ask yourself why patients stop taking meds and or seek treatment?

Using Lithium Carb caps/10mg Zyprexa/Cogentin as a typical combo example per month:

$816.15

One more comment regarding "giving the doctor a budget within he must operate."

The doctor needs to start with him/herself. The 130.00-$150.00 per 30 minute charges are outrageous, some docs charge that for 15 minutes. My daughter's outpatient psychiatrist no longer accepts any insurance. I have to manually submit the claim for a 60% payback.
We need insurance co-pays (for instance I can get Seroquel from my general practioner and pay a $20.00 co-pay)and insurance parity across the board.
The price of going to an intake as a new patient to a private practice psychiatrist is often 250.00 for that first 30 minutes.

Until the psychiatrists themselves get in this same thought pattern of low cost medications,and what they charge for services then it is like driving a car with 3 wheels.
This is why I always ask for those famous pharma samples I know the pscyhiatrist has stocked on hand from the reps.
I can walk out of there with just about any medication possible. Way to pass on savings pdoc! It still barely balances out getting free meds and paying for overpriced medication management sessions.
It is time for a major overhaul, let's call it Mental Health care R E F O R M.

Sadly, I feel reform will not happen, because it is such a lucrative market.

The evidence is mounting that the knee-jerk assumption that atypicals should be the first line medication for treatment of psychoses is diminishing. Thanks to the Pharma funded medication algorithms, the switch has largely been made to atypicals in the public mental health system.

But, it has been very costly. For example, the Medicaid expenditures for antipsychotics increased 160% between 1995 and 1998 when the total number of prescriptions only increased 20%. That is because the proportion of atypical prescriptions grew from 17.5% in 1995 to 51% 3 years later in 1998. The cost grew as well, from $487 million in 1995 to $1.3 billion in 1998. Imagine how much more of the pie the pharmaceutical companies are getting now, 8 years and many marketing dollars later. Also imagine if that money were available for services, such as medication education and close monitoring for efficacy and side-effects. Decisions about medication should be based on efficacy and side-effects, not classification alone. And Clozapine shouldn’t be abandoned just because it is off-patent and isn’t being marketed by the Big Pharma reps. If money were freed up for better medication management services, clinicians would be in a better position to evaluate efficacy and side-effects and make more informed prescribing decisions.

This is from TAC's blog, Aug. 4, 2006. They have been speaking out about the cost of meds for a long time.

Thanks for your blog, I read it very often.