[costello]

Opinion piece in the New York Times:

PHILADELPHIA — A FEW months ago, a patient came to our hospital, seeking help. One of us, Edward, was on the team that treated him. He was pleasant, if slightly withdrawn, and cogent. He was a college graduate in his 20s and had recently been fired from his job as a high school math teacher, because of unexpected absences. He had come to believe that government agents were conspiring against him, and he had taken to living out of a truck and sleeping in different parking lots. By the time he came to us, he was exhausted. A diagnosis became clear: he had schizophrenia.

We admitted him to the hospital, and after a few days, with his symptoms under control, we released him. Unfortunately, we prescribed a medication for him that could cause significant, permanent harm, instead of an equally effective drug with milder side effects — all because he was uninsured.

Schizophrenia, which affects 1 percent of the population and emerges in the late teens to early 20s, is deeply misunderstood. People who suffer from it are often suspected of being dangerous, but this is not usually the case, and antipsychotic drugs are very effective. Our patient was exactly the kind of person who, with the right treatment, could have weakened the stigma surrounding schizophrenia.

Antipsychotic drugs fall into two classes: the older ones, like Haldol, and newer ones, like Abilify and Latuda. Both classes are equally effective at treating some of the worst symptoms of schizophrenia, specifically the hallucinations, delusions and paranoia that cause social alienation. (They’re not effective for treating “negative symptoms,” like low motivation.)

But the older drugs can cause a multitude of serious side effects, including a potentially devastating one called tardive dyskinesia. This condition involves unsettling, animalistic smacking and wagging of the lips and tongue. At its extreme, it can affect the entire body. It occurs in 20 percent or more of patients who take the drugs long-term, and it tends to start so mildly that patients can’t identify it in time to stop taking the drugs. It is often irreversible.

The newer drugs have lower rates of tardive dyskinesia (estimates vary, but most likely less than half or one-third the risk), although they can cause weight gain and predisposition to diabetes, among other side effects. The newest among them, however, have decreased these risks, too. And a 2006 study showed that patients were more likely to keep taking the new drugs than the older ones.

As a result, most psychiatrists prefer the newer drugs, especially for younger people, and they should have been the clear choice for our patient.

He didn’t have the luxury of choice, however, because he was uninsured, and he was explicit about the fact that he didn’t have much money to spend on medications. So we had to prescribe him Haldol, which costs about $20 per month, instead of one of the newer drugs, which can cost more than $600 per month.

Had our patient been lower functioning, he might have qualified for disability benefits and Medicaid, which would have covered the new drugs. Many people who are much more severely affected — homeless individuals who are floridly psychotic, for example — receive the newest and best of our antipsychotics. They spend more time in the hospital and get more intensive case management.

Our patient was, in effect, penalized for being employable. People with schizophrenia are especially poorly suited for an employer-based health insurance system, because even if they are capable of working, their symptoms can lead to frequent job changes and firings. The Affordable Care Act should help, as it expands Medicaid to all people earning up to 138 percent of the federal poverty line. Pennsylvania, however, has so far decided not to participate in the expansion.
Some might argue that our treatment choice was an example of cost-effective medicine. New antipsychotics aren’t clearly more cost-effective than older ones, so why not save hundreds of dollars per month? For our patient, though, it isn’t simply the difference between more or fewer symptoms. It’s potentially the difference between a life spent gainfully employed thanks to consistent treatment, and a life spent in and out of treatment and increasingly out of control, stopping and starting medication, and always under threat of a disfiguring side effect.

A 2002 study showed that 70 percent of those with well-controlled schizophrenia still worried about being viewed unfavorably because of their illness. Better treatment for patients like ours is an important step in changing this. Hopefully he can become a model of how well those with schizophrenia can integrate into society. But if he ends up getting tardive dyskinesia, he may be alienated even further.

These issues will be amplified as progress is made in discovering the mechanisms of psychiatric disease, as it likely will be, thanks to the billions of dollars that are now going to neuroscience research. We can already see the results of that kind of investment in oncology, where extravagantly expensive specialty drugs are coming on the market. But as we make much-needed progress and develop new, expensive treatments that are clearly superior to old, cheap ones, we have to ask: Will those with the most to gain still receive a lower standard of care?

Edward Larkin is a second-year medical student at the University of Pennsylvania, where Irene Hurford is an assistant professor in the department of psychiatry.

http://www.nytimes.com/2014/08/13/op...-penalty-.html

[costello]

I personally found the piece irritating. Atypicals do have serious side effects too. And those side effects do sometimes cause stigma and non-compliance. You get the feeling the authors work for a pharmaceutical company.

My question is why are atypicals so much more expensive. My son's medication, olanzapine, is off patent, and he takes the generic. Nevertheless, it stills costs something like $400 per month - which the tax payer picks up the bill for.

Btw my son has never been prescribed one of the older APs - even before he was on Medicare.

The comments to the story were more insightful IMO.

[Sometimes psychotic]

I saw this and I generally agree we wait until its too late because traditional insurers have nothing to lose since most will be on gov programs if they get sick enough---there is little incentive for them to allow things like abilify that cost more---I know I had to get special approval with my first insurance but not bc/bs that I'm on now. So even if you have quality insurance there is an issue relative to people on disability----no insurance though, obamacare should take care of that to a great extent----its something I'm very glad of because I know I may one day end up working retail or some equivalent where there is no insurance.

[costello]

Loved this comment from Richard:

As a psychiatrist in practice for 35 years, I am not impressed by this column whose first author is a second year medical student, with co-author an assistant professor of psychiatry. This column is exactly the kind of verbiage which the big drug companies love to see in print. It is certainly true that schizophrenia carries a stigma, and that well-insured patients are more likely to receive more expensive, brand-name medications (which earn big bucks for those drug companies). However, these new, expensive ones cause major side effects which are no fun: diabetes, heart disease, and strokes. When one discusses with patients whether they'd rather risk tardive dyskinesia or those potentially life-threatening metabolic diseases, it's a close call for many. In short, everything should depend on patient choice, NOT on the marketing efforts of multi-billion-dollar drug companies.

[Sometimes psychotic]

Originally Posted by costello

I personally found the piece irritating. Atypicals do have serious side effects too. And those side effects do sometimes cause stigma and non-compliance. You get the feeling the authors work for a pharmaceutical company.

My question is why are atypicals so much more expensive. My son's medication, olanzapine, is off patent, and he takes the generic. Nevertheless, it stills costs something like $400 per month - which the tax payer picks up the bill for.

Btw my son has never been prescribed one of the older APs - even before he was on Medicare.

The comments to the story were more insightful IMO.

the $400 is because they can----the bulk of people are on medicare/medicaid and its required by a special law to be covered for those patients so they can charge whatever they want---this is why med part D wanted to cut the protection on ADs and APs---so the pharms would lower the costs---

[Sometimes psychotic]

Originally Posted by costello

Loved this comment from Richard:

This is totally true I was like----what? why on earth did they have a med student write this?

[costello]

Another great comment from Dr Claiborn. It's just great to see there are providers out there in practice who understand this stuff.

While the newer, sometimes called second generation or atypical antipscyhotics produce a much lower incidence of TD they routinely lead to development of a metabolic syndrome that includes elevated blood lipids and diabetes. Neither is a great choice. Then there is the fact that we now know that long term use of high dosages of antipsychotics leads to higher rates of disability than treatment with these medications at lower dosages for shorter periods of time. Even the Journal of the AMA came out with an editorial acknowledging this. There is also solid evidence that psychosocial treatments, such as cognitive behavioral therapy for psychosis, often provide important benefits in both positive and negative symptoms of schizophrenia. Unfortunately such treatments don't bring big profits to drug companies so they are not agressively promoted and may be almost impossible to find in most parts of the country.

[costello]

Originally Posted by Sometimes psychotic

the $400 is because they can----

Yep. That's all it is. It's because the big corporations own the country now. I wish the average voter would figure this out and elect people who'd make some rational changes.

[Nightside of Eden]

Um, they didn't HAVE to prescribe Haldol simply because money was an issue. There are tons of drug coupon and assistance programs out there for the newer, more expensive drugs. I was able to get Zyprexa for $25.00/month without insurance by using these programs (it was $600+ without them, despite being generic). There are coupons for cheap Seroquel too, as it's also generic.

Also, Haldol is still considered the "gold standard" anti-psychotic by a fair number of doctors, meaning it's more effective at stopping psychosis than most of the newer drugs. The dosage has been fine-tuned a lot in recent years to lower the risk of TD too. One reason Haldol has such a bad reputation is because doctors used to prescribe it at up to 10 times what is now considered the proper dosing schedule.

Of course it sucks that finances can play a large part in treatment. This is why I support Medicaid expansions and universal healthcare coverage. It's hardly just a problem in mental healthcare, but a problem for anyone which a chronic condition where the drugs can be expensive. But many of the statements in this article are just erroneous. Haldol isn't a bad drug, and for gods' sake, if he doesn't want to take it I'll personally send him the link for $25.00 Zyprexa--something I, as a high school drop-out, am apparently more capable of finding than all those doctors and college professors put together.

[Sometimes psychotic]

Originally Posted by Nightside of Eden

Um, they didn't HAVE to prescribe Haldol simply because money was an issue. There are tons of drug coupon and assistance programs out there for the newer, more expensive drugs. I was able to get Zyprexa for $25.00/month without insurance by using these programs (it was $600+ without them, despite being generic). There are coupons for cheap Seroquel too, as it's also generic.

Also, Haldol is still considered the "gold standard" anti-psychotic by a fair number of doctors, meaning it's more effective at stopping psychosis than most of the newer drugs. The dosage has been fine-tuned a lot in recent years to lower the risk of TD too. One reason Haldol has such a bad reputation is because doctors used to prescribe it at up to 10 times what is now considered the proper dosing schedule.

Of course it sucks that finances can play a large part in treatment. This is why I support Medicaid expansions and universal healthcare coverage. It's hardly just a problem in mental healthcare, but a problem for anyone which a chronic condition where the drugs can be expensive. But many of the statements in this article are just erroneous. Haldol isn't a bad drug, and for gods' sake, if he doesn't want to take it I'll personally send him the link for $25.00 Zyprexa--something I, as a high school drop-out, am apparently more capable of finding than all those doctors and college professors put together.

Those don't last forever so people end up switching meds when they expire which has risks of its own---and I know for some like abilify, insurance is required they just help with the copay----

[costello]

Originally Posted by Nightside of Eden

There are tons of drug coupon and assistance programs out there for the newer, more expensive drugs.

Some of the comments point that out. My son was always able to get the newer medications, despite being unemployed and uninsured.

Also, Haldol is still considered the "gold standard" anti-psychotic by a fair number of doctors, ...

I agree.

I, as a high school drop-out, am apparently more capable of finding than all those doctors and college professors put together.

I suspect the reason for this op-ed piece is less to solve a real problem than to sway public opinion in the direction of spending more tax payer money on drug company products. The many insightful comments to this article won't appear in the print version, of course, and won't be read by many online readers. So the problem is framed as "old drugs bad, new drugs good, lives destroyed by being forced onto old drugs because of stingy tax payers."

[Nightside of Eden]

Originally Posted by Sometimes psychotic

Those don't last forever so people end up switching meds when they expire which has risks of its own---and I know for some like abilify, insurance is required they just help with the copay----

I agree that it's imperfect, but the article didn't even mention the assistance programs, which will ideally tide you over until you obtain insurance coverage either through employment or Medicaid. Doctors prescribing something they don't feel is proper treatment without even trying to get the patient assistance verges on unethical, IMO. I don't think it has much of anything to do with mental healthcare stigma either. My mother's diabetic supplies and insulin would cost over $800/month without insurance, and that's not a mental health condition. It's a systematic problem with the entire pharmaceutical industry.

The attitude that "newer treatments are better" irks me even more, though. Diabetes, weight gain, and metabolic disorders are nothing to dismiss, and they happen with many atypical APs at a rate higher than the 20% TD risk that article listed for Haldol (I'd like to know where they got that number too, and what the dosage schedule used in the study was). One woman in my bipolar support group almost died from fluid retention caused by an atypical AP screwing with her metabolic system. Abilify and Latuda lower these risks some, but they still exist, and both those drugs have a lower efficacy rate at treating positive psychotic symptoms. It's a real "pick your poison" situation and Haldol is a perfectly reasonable treatment option.

[newtus]

it really is a pick your poison situation. its all between TD or metabolic issues. Its a lose - lose situation to me. in my mind. ive been on haldol off/on for exactly a year now. since august 2013. half the time it was the injections. i was taking 100mg every 3 weeks. on the injection for 7 months. it made me gain weight and a bit sleepy but that was it. i now am back taking it in pill form in 15mg a day. the side effects are virtually gone now. idk why that is in pill form but it is. apparently.

ive taken every atypical and typical med approved by the FDA for the past 8-10 years now. except i havent taken clozapine. the atypicals hold true to giving weight gain as i ALWAYS have gained weight on them. including latuda and abilify.

on the typicals i just got really sleepy mostly. low weight gain but still weight gain. idk why that is for ME that i still gain weight on the typicals. but the weight is A LOT less than the atypical weight gain. so far anyway.

anyway the meds rarely help me anymore. the reason ive gone through all of them is because they either work OR they cause me massive weight gain. THE WORST BEING SEROQUEL for me. i gained 80 pounds on that. i became prediabetic on that. THANKFULLY i didnt get diabetes. and i lost all the 80 pounds. but the effects of the high dose of haldol injections has caused me to gain 40 pounds. during that 7 month period.

when i first took haldol in pill form the VERY FIRST TIME i got a dystonic reaction. i only got that 1-2 times. i dont get it anymore.

[Sometimes psychotic]

http://www.nytimes.com/2014/08/22/op...enia.html?_r=0

Follow up letters...