Rising Mental Health Drug Costs: How Should Managed Care Respond?

Sheila Fifer, PhD; Patricia Marken, PharmD; Joyce Kamanitz, MD; Antohony Kotin, MD; Norrie Thomas, PhD, MS, RPh

In This Article

What is Driving up Outpatient Mental Health Drug Costs?

The CWG members cited 3 key forces as contributing to cost increases: polypharmacy, consumer-driven care, and chronic medical conditions with underlying behavioral disorders. These 3 trends are unlikely to diminish and warrant specific interventions with both patients and providers to improve quality of care.

Treating patients with multiple mental health drugs has become more common not only among mental health specialists but also among primary care prescribers. Some CWG members said that they regarded the term "polypharmacy" as both imprecise and somewhat pejorative. They suggested that the terms "rational polypharmacy" or "multiple drug therapy" better describe the concurrent use of more than one medication when necessary and appropriate.

An example of polypharmacy is the use of more than one mood stabilizer for a patient in the depressed phase of bipolar affective disorder or for a patient with psychotic depression. In contrast, polypharmacy has also been used to describe duplicate, or duplicating, therapy, which is when clinically questionable multiple medications are used in cases in which monotherapy could be effective. One example of such therapy is the use of 2 SSRIs plus an SNRI for a depressed patient. Polypharmacy may be a rational therapeutic choice during some phases of an illness—for example, when a patient is acutely ill—but may become unnecessary once a patient is stabilized.

Regardless of the terminology, most CWG members agreed that more patients with mental health disorders are being treated with 3 or more separate medications. Why?

Treatment of Multiple Mental Health Conditions. Panelists suggested that providers, as well as many patients, are now much more aware of the prevalence of coexisting mental health disorders. Providers who treat patients with depression, for example, look for and try to manage co morbidities such as anxiety and substance use disorder with additional drug interventions. Grouping mental disorders into clusters helps explain behaviors and mechanisms of treatment more clearly. Work is under way to further enhance the terminology used to describe multiple medical conditions.[6]

Additional Treatment Given too Soon Before Efficacy of the Initial Treatment. This source of multiple—and often excessive—prescriptions can arise when:

  • A second medication is added early in treatment because of an incomplete patient response. One example would be augmenting an antidepressant at the second week of treatment. Theoretically, 4 to 8 weeks are required to evaluate whether an antidepressant is working, but additional medications may be added because of a lack of patient response. Augmenting antidepressant therapy too soon, before a proper assessment can be made, may needlessly increase treatment complexity and cost.

  • An appropriate use of multiple drugs initiated early in treatment when the patient was acutely ill continues indefinitely after the patient is stabilized. For example, a hypnotic medication may be prescribed for new-onset insomnia in a depressed patient and continued long after the patient's symptoms of depression and, presumably, associated insomnia have improved.

  • Physicians may be encouraged to write multiple prescriptions because patients do not understand that the drug needs to be taken for 4 to 8 weeks before they can feel better. Patients may comment to their prescribers about continued symptoms and may subsequently receive additional prescriptions for mental health medications, not necessarily from the same physician. Patricia Marken, PharmD, suggested that the outcomes of patients receiving mental health treatment would benefit from clear treatment plans that include mea surable goals and time frames for reevaluation of response, especially for patients on complicated medication regimens or those taking multiple agents.

Instead of Hospitalization or to Avoid it. Patients today are not hospitalized for psychiatric conditions as frequently or as easily as in the past. Instead, multiple medications may be needed to manage an acutely ill patient in the outpatient setting. "We use multiple drugs more and more to keep patients out of the hospital," said one group member. "And once the patient is stable, there is a tendency to not want to take any drug away and possibly upset the balance."

A related pattern contributing to long-term polypharmacy, suggested Joyce Kamanitz, MD, is the transfer from inpatient to outpatient care. When the patient is discharged, the communication among providers may not be complete. Thus, patients may continue taking multiple medications indefinitely. Marken noted, "We are just not good at getting patients off drugs and need to reevaluate our patient's need for medication."

To Avoid or Minimize Side Effects. Polypharmacy can result when prescribers try to avoid adverse effects from medications such as lithium and mood stabilizers, including Depa kote (divalproex) or Trileptal (oxcarbaz epine), said Kamanitz. Rather than use one mood stabilizer at a relatively high dose, prescribers may employ multiple mood stabilizers at lower doses in an attempt to avoid side effects while achieving efficacy. For example, instead of prescribing lithium, 1200 mg/d, to stabilize a person with bipolar disorder, a physician might prescribe Topamax (topiramate), 50 mg/d; lithium, 300 mg bid; and oxcarbazepine, 300 mg bid. Although such a strategy can be successful, Marken noted that patients on complex medication regimens need explicit instruction and frequent monitoring in order to benefit and comply.

Prescribers are also increasingly using a second medication to manage medication-induced adverse effects, said Kamanitz. "For example, SSRIs can cause sexual dysfunction. A second agent, such as an SNRI, might be added to address this problem."

Mental health care has become increasingly consumer-centric. Consumers are asking for—and receiving—more diagnoses and more drug treatment.[6] Three forces have encouraged the mental health patient to become a more proactive consumer. First, pharmaceutical firms' direct-to-consumer (DTC) advertising motivates and equips patients to make both general and specific drug requests of their physicians. Advertising has made consumers more aware of men tal health conditions and of specific drugs used in the treatment of those conditions.

The much-advertised drugs for sleep disorders (Ambien), anxiety disorders (Effexor, Paxil, Zoloft), attention deficit hyperactivity disorder (Strattera), and depression (Effexor, Paxil, Wellbutrin, Zoloft) are requested and prescribed at greater rates than medications that are not widely advertised to consumers. In one study, patients' requests were shown to significantly influence physician prescribing in major depression and adjustment disorder.[7] Researchers concluded that DTC advertising may have dual effects on physician prescribing by discouraging underuse and promoting overuse.

Second, employers' emphasis on partnering with—that is, shifting health care choices and costs to—employees and retirees has also encouraged mental health patients to be more assertive about their care. Previously, the stigma associated with mental health conditions restrained patients from actively seeking a diagnosis and certainly from requesting specific medications. Now, patients may not only suggest to their physician that they have a mental health disorder but also may specify the name(s) of the widely advertised drug or drugs with which they would like to be treated.

Third, patients may have to make additional copayments for prescription medications because the physician is titrating drug doses and adjusting the regimen. If the first medication does not elicit the anticipated response, the physician will change therapy. The prescription claims record will show multiple medications even though only one medication was being used at a time. In the early phases of treatment, changes in therapy are common and may result in waste and unused medicine, which are real drug costs. Utilization management systems must be "smart" to detect titration at the initiation of therapy. Physicians, in efforts to limit patients' copayments, which are increasing, may use samples during titration. Brand-name, more expensive, and newer medications are available for patient sampling; generics typically are not.

Data from employers and Health Plan Employer Data and Information Set (HEDIS) have articulated performance measures for health plans on the management of chronic medical conditions. Screening for and treatment of depression and other psychiatric conditions are resulting in disease-management programs for diabetes, back pain, cancer, stroke, and heart disease.

Kamanitz indicated that "primary care physicians are encouraged to consider the increased morbidity and mortality in a chronic medical condition caused by a concomitant depression or anxiety disorder. Adding an antidepressant to a drug regimen can reduce pain, lower levels of inflammatory markers of cardiac illness, and increase compliance with diabetes regimens."


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