Assessing the Costs of Second-Generation Antipsychotics

In the Economic Grand Rounds column, Jerrell and colleagues describe how a broad range of U.S. health systems have failed to implement recommended cardiometabolic monitoring for patients treated with second-generation antipsychotics. The authors call for increased vigilance by mental health care providers and greater administrative support from health systems to meet these standards.

In pursuit of parity, providers have focused on obtaining additional resources to provide optimal mental health care. However, greater support is also needed to monitor our patients' general medical health, particularly for complications resulting from psychiatric medications. Mental health providers should therefore advocate for the system changes needed to include cardiometabolic monitoring as an integral part of psychiatric care.

Jerrell and colleagues raise the question of why many systems lack support for cardiometabolic monitoring. The answer may have to do with the immediate costs of implementing monitoring programs in mental health settings, compared with the unknown costs or cost-savings of detecting cardiometabolic conditions. The decision to avoid known, immediate costs and accept potential unknown future costs may be a rational one for administrators. Greater understanding of the cost-effectiveness of cardiometabolic monitoring is therefore needed.

We should also not lose sight of the known costs of second-generation antipsychotic use, which are already staggering. Use of these drugs for conditions other than schizophrenia (patients with schizophrenia now account for only one-fourth of users) has led two of them—aripiprazole and quetiapine—to rank among the top ten best-selling medications in the country, with sales of over $3 billion each in 2010. In recent years these agents have been approved for patients with treatment-resistant major depression, and aggressive direct-to-consumer marketing has begun. We have also seen more “off-label” use for anxiety disorders. Assessing the total costs of using second-generation antipsychotics for these common mental health conditions is particularly important because there are effective alternatives with lower prescription and monitoring costs.

By 2003, when the U.S. Food and Drug Administration issued warnings about metabolic side effects, second-generation antipsychotics had already displaced first-generation antipsychotics as the standard of care for schizophrenia. Before these agents displace effective treatments for depression and anxiety disorders, we should fully understand the consequences of their use to treat these disorders, as well as the comparative effectiveness of alternative treatments, the extent and costs of supports needed for cardiometabolic monitoring, and adverse long-term outcomes.