Atypicals Have No Advantages

As I mentioned on Friday, the latest results of the landmark, NIH-funded CATIE study, which measures the performance over 18 months of second-generation antipsychotics versus one first-generation antipsychotic in treating schziophrenia, came out in the American Journal of Psychiatry. This is the second--and final, I believe--phase of results from the study and this time out (I have blogged about the other phase here) what researchers tried to measure is whether there was any cost differential between using older drugs versus the newer ones and whether there was any quality of life differential between the two groups of drugs.

I have read the primary paper, the accompanying editorial, an accompanying paper assessing whether the same kind of potential differentials could be detected in other randomized studies of similar drugs in schizophrenia, as well as a final CATIE paper on the effectiveness of switching meds on patients. Needless to say, my head is full and my eyes are tired. AJP has not updated its website with the relevant links yet, so I'll pass those along later.

In addition, a recent somewhat-analogous British study came to much the same conclusions.

There is no need for a thorough treatise here. The atypical antipsychotics--Zyprexa, Seroquel, Risperdal and Geodon--proved to be much more expensive (to the tune of $300 a month) than was the lone old antipsychotic (perphenazine, a medium-core typical antipsyhcotic), once all associated health care costs (meds, inpatient and outpatient treatment) were taken into consideration. Second, the newer drugs did not improve patient quality of life--the researchers hit upon a complex index of symptoms, side effects, cognition--over perphenazine. What's more, regardless of the drug involved, patient quality of life didn't improve much at all, despite patients being med-compliant. Sigh.

At this point, the atypicals have lost whatever perceived value they once had, although their respective makers were out with lame attempts to spin the study's results soon after they became available. It is discouraging to me that after a decade-plus of feeding these meds to profoundly-ill schizophrenics, and offering up reams of promises in the process, that they have not turned out to be the silver bullet or the great hope that everyone in the mental health world thought them to be. I first noticed that the atypicals didn't seem to improve things for schziophrenics in 2004, when I did a bunch of reporting on community mental health work in the Seattle area and in Western State Hospital. The positive and negative symptoms were still as present as the first time I began paying attention to chronic schizophrenics in the mid-1990s. In fact, I was so confused by the discrepancy that I didn't explore it formally in print for another year. It's been interesting over the past year to see my reportorial hunches turn out this way.

I wish that I had been wrong. So do millions of schizophrenics.

Really, all that's left to be said is that, despite these findings, insurance companies and bean counters should not restrict access to these drugs for patients because of the cost imbalance. It should be a choice made by their doctors and themselves, and access should be open and equal.

That said, however, it is clear to me that the time has come for researchers, doctors, patients and health care systems to band together and press the pharma comapnies to dramatically cut the prices on the atypicals. These drugs cost anywhere from 8 to 20 times the cost of older, off-patent meds, but in no way is the cost differential justified in terms of clinical performance or patient quality of life.

NAMI and MHA and the American media have an important role to play in helping to make that happen. So far, they are silent. But, then, so is damn near everyone else.

There are other implications as well, but those are for another post.