Last month's Psychiatric Services offers a "spin free" take on
the clinical implications of CATIE (see Experts Analyze Real Meaning of CATIE
Study Findings). But what do the findings suggest about how society should
allocate public dollars for treatment of severe mental illness? And are
cost-effectiveness studies alone reliable for making sound public policy?
Surveying the wider landscape of rising American health care costs, Robert
Rosenheck, M.D., told Psychiatric News that CATIE suggests that
second-generation antipsychotics (SGAs) are not worth the enormous
expenditures they have entailed.
"I feel more strongly than most that there is an urgent need for
action," he said. "We as health care professionals tend not to
think about money, but taxpayers are paying a lot of money for [SGA] drugs
that have been shown to have no greater benefit" than less-expensive
"Most people dodge the question by saying we need individual
therapies for individual patients, rather than answer the question of what to
do about these expenditures," Rosenheck said. "Atypical
psychotropics are not the reason we have a cost problem in the United States,
but if we don't address questions of national concern that are in our
professional area, how can we expect others to do the same?"
He told Psychiatric News that the VA in Connecticut has instituted
an effort to educate clinicians about costs associated with SGAs and to train
clinicians in the use of FGAs.
But at the public-policy level, Rosenheck is pessimistic about the
prospects for reform.
In a paper in the special section titled "Second-Generation
Antipsychotics: Cost-effectiveness, Policy Options, and Political Decision
Making," Rosenheck reviewed several mechanisms for reining in costs:
utilization management, pricing mechanisms, and government regulations. For
each, he found that political considerations make it unlikely that any of them
will be implemented.
Rosenheck concluded that high expenditures for antipsychotic medications
are likely to continue without concomitant gains for public health.
But his prescriptions for reining in costs were countered by economist
Richard Frank, Ph.D., who argued that cost-effectiveness alone is not
sufficient for making sound public policy.
In another report in the Psychiatric Services issue, titled"
Policy Toward Second-Generation Antipsychotic Drugs: A Cautionary
Note," Frank wrote, "It may be premature to adopt such policies
primarily on the basis of CATIE results....The advocacy community is
painfully aware that payers have frequently seized on uncertainty about
evidence of effectiveness to limit mental health insurance coverage, driven
partly by economic incentives to avoid enrolling costly patients....It would
therefore be wise not to overemphasize a single set of results and to
understand the importance of nonscientific input about how policy works in
In the report "Impact of the CATIE Findings on State Mental Health
Policy," Joseph Parks, M.D., and colleagues described the enormous
burden—as much as 10 percent of some states' total pharmacy budget for
Medicaid—that funding for SGAs placed on state mental health budgets
prior to the appearance of CATIE. The team summarized policy recommendations
of the Medical Directors' Council of the national Association of State Mental
Health Program Directors in the wake of CATIE. Broadly, they are as