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Director’s Update: NIMH Perspective on Antipsychotic Reimbursement: Using Results from the CATIE Cost Effectiveness Study

The recent publication (December 1, 2006, American Journal of Psychiatry) of the cost-effectiveness results from the National Institute of Mental Health (NIMH)-funded Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) has raised questions among advocates, families, and clinicians about reimbursement policies for antipsychotic medications.

Antipsychotics have now become the fourth largest group of medications prescribed in the United States, with a collective cost expected to surge past $10 billion this year. About 80 percent of the prescriptions for antipsychotics are paid via the public sector. The new atypical medications, representing 90 percent of the current market, are approximately 10 times the cost of the older conventional antipsychotics.

In a report in the September 22, 2005, New England Journal of Medicine, the CATIE research team compared discontinuation rates with four atypical antipsychotics (olanzapine, quetiapine, risperidone, ziprasidone) and one older conventional antipsychotic (perphenazine). The results demonstrated few differences overall among the various medications. The older medication, perphenazine, was as well tolerated as the newer compounds and as effective as three of the four newer drugs. The fourth compound, olanzapine, was slightly better than all the others in terms of discontinuation and hospitalization rates but was also associated with higher rates of weight gain and metabolic side effects.

The December 1, 2006 study analyzed the economic implications of the CATIE results and found that, because perphenazine was as effective overall and less expensive, the older antipsychotic medications such as perphenazine still have a valuable role in treating schizophrenia. The results should encourage doctors to reconsider the use of these older medications as another choice for patients with schizophrenia. This study should help expand the current list of medications most commonly used for schizophrenia, rather than restrict or reduce access to any of the antipsychotic medications. NIMH believes that this is important for the following reasons:

  • Although the CATIE results suggest little difference in the overall effectiveness for the entire cohort, individual patients respond differently to different medications. To say the medications are equivalent is not to say they are identical. There is substantial variability in the response of individuals to these treatments. Future studies will focus on predicting individual patterns of response.
  • There are additional outcomes to consider. Upcoming reports will describe the effectiveness of these various medications on quality of life and cognitive deficits. Cognitive impairment is a central clinical feature of schizophrenia and is strongly associated with functional outcomes.
  • CATIE was limited to people with chronic schizophrenia who were moderately treatment-resistant. People with acute, first onset schizophrenia and those with other psychotic disorders were not included in this study. These patients may respond differently to antipsychotic medications.
  • CATIE was an 18-month study. While this is longer than most clinical trials it is not long enough to fully consider whether patients would develop serious long-term side effects such as tardive dyskinesia, diabetes, or other medical conditions that can develop even years after starting medication.

Taking all these points into consideration, NIMH holds that families and physicians need more, not fewer, choices for addressing schizophrenia. A one-size-fits-all approach for treating schizophrenia could be harmful, essentially turning the clock back 40 years to an era when conventional antipsychotics were the only medications available for patients with this chronic, disabling disorder affecting 3.2 million Americans.