The Corpus Callosum

Best Buys for Schizophrenia Treatment

I have to admit, I was started to see a Consumer Reports article on the
“Best Buy” drugs for the treatment of schizophrenia and bipolar
disorder.  So now
treating mental illness is like buying a toaster oven?
 Seriously, at first
it seemed kind of inappropriate.  After all you cannot assess
pharmaceuticals the same way you assess ordinary consumer products, can
you?  

First, let me say that I like the magazine.  I don’t
subscribe to it, but I do look at it from time to time, and I do
consult it for certain things.  For instance, in 1995, when I
went to buy a microwave oven, I first went to the bookstore in the mall
and looked at one of their compilations.  I had my son read
it, actually, who was seven at the time.  He asked me some
questions, such as “Which is more important to you, operating speed,
ease of use, or number of features?”  We went through the
process of selecting a model, and put the book back on the shelf.

Then we went to Sears.  A salesman came up to us and asked if
he could help.  My kid blurted out “We’re looking for a
Kenmore microwave oven, model number 4522672,” or something like that.
 I don’t actually recall the model number, although it was
quite a few digits.

After the salesman picked up his jaw, he said, “uh, OK, follow me.”
 

They did not have that exact model any more, so we got the most similar
one.
 It worked great; still does.  Problem solved.

But can you do the same thing with drugs for schizophrenia?
 Imagine going to the doctor and having your son blurt out,
“He needs to be on Zyprexa.”

It could happen, of course.  No one is safe from these
diseases.

I was skeptical when I read the synopsis, but I must say, the actual
report is fairly good.  
href="http://www.crbestbuydrugs.org/drugreport_DR_antipsychotics.html"> style="font-weight: bold;">

href="http://www.crbestbuydrugs.org/drugreport_DR_antipsychotics.html"> style="font-weight: bold;">Treating Schizophrenia and
Bipolar Disorder

Our Recommendations — A Summary

Antipsychotic drugs help many people with schizophrenia live more
meaningful, stable lives with fewer – and sometimes no
– periods of hospitalization.  But they are a highly
problematic class of medicines.  A sizeable percentage of
people with schizophrenia get little or no benefit when they take an
antipsychotic while others get only a partial reduction in
symptoms.  Side effects pose a major barrier to continuous
use.  In studies, for example, three of every four people
stopped taking an antipsychotic or switched to a different one within
18 months.

Newer and quite expensive antipsychotics marketed heavily to doctors
over the past 15 years have largely eclipsed an older generation of
drugs developed in the 1950s and 1960s.  Research for years
appeared to indicate that the newer drugs were better, largely because
they had fewer side effects.  But recent large-scale studies
now indicate that, overall, the older drugs work just as well, at far
lower cost.

Taking effectiveness, safety, side effects, patient variability, dosing
convenience, and cost into account, we have chosen the following as
Consumer Reports Best Buy Drugs:

    * Generic perphenazine – as
initial treatment for people newly diagnosed with schizophrenia and for
people with schizophrenia who have failed on a newer drug and whose
doctor thinks perphenazine is worth a try.  Patients taking
perphenazine should be monitored closely for muscle tremors and spasms.

    * Olanzapine (Zyprexa) – for
certain people with schizophrenia who take perphenazine first and get
no or minimal benefit and/or experience intolerable side
effects.  Zyprexa is not a good option, however, for people
who are overweight, have blood sugar abnormalities, diabetes, or heart
disease.

    * Risperidone (Risperdal) –
for people with schizophrenia who take perphenazine first and get
minimal benefit and/or experience intolerable side effects.

    * Generic clozapine – for
people with moderate to severe schizophrenia who have not responded at
all to two or more other antipsychotics and have had little 
reduction in symptoms.

The choice of generic perphenazine – if a patient responds
well to it – saves about $200 to $500 a month ($2,400 to
$6,000 a year) compared to Zyprexa and Risperdal, depending on the dose
required.

We make no choice of a Best Buy antipsychotic for people with bipolar
disorder. There is not enough evidence to do so.

This information and our report were last updated in November 2006.

href="http://www.crbestbuydrugs.org/PDFs/AntipsychoticsFINAL.pdf">i-13899a48ae372c00e692df2ad83e8d06-acrobat-icon-small.gif href="http://www.crbestbuydrugs.org/PDFs/AntipsychoticsFINAL.pdf">Full
Report (400k PDF)

Note, however, that I endorse the full report, but find the synopsis a
bit misleading.  I also worry a bit that people might look at
certain summary statements, and mistake them for conclusions, without
carefully reading the whole thing and drawing their own conclusions,
which is the only way to make good use of such a report.
 Also, there are some statements that worry me a bit:

Don’t take two
or more antipsychotic medicines at the same time. This increases the
risks of side effects, and the benefits are unproven.

It is true that use of multiple antipsychotics does increase risk, and
cost, and there is no clear evidence of benefit…in a style="font-style: italic;">population of
people.  That does not mean that no individual will benefit,
just that in a population, it is hard to show a systematic benefit.
 Although you generally want to stick with treatment
strategies that are backed by a stack of evidence, sometimes
circumstances are such that it makes sense to try things that do not
have a solid evidence base.  That is a complex issue, though,
and I do not fault them strongly for not explaining that fully.

Because of the risk it
poses, clozapine is prescribed only for people with schizophrenia who
have not benefited from any other antipsychotic drug.

Clozapine is used for persons with bipolar disorder, too, and
schizoaffective disorder.  It is clearly the most efficacious
drug we have.  It is also the most dangerous, and pretty much
everyone gets adverse effects of some sort.  But, if you ask a
bunch of psychiatrists which drug they would want to take if they
developed schizophrenia, some of them would want to start with
clozapine.

By the way, I’ve never started someone on clozapine without first
trying at least two atypicals, and one typical.  Just because
I think I would want to start with clozapine does not mean that I
recommend that others do so.  I am probably a lot more willing
to face the risks than most people would be.

To get to the main point: even though it may seem odd to think of a
“best buy” drug for schizophrenia, there is some sense to their
approach.  They clearly did a lot of work on this, and it is
worth reading.  It is important to read the whole thing,
though, before making any important decisions, and to keep in mind –
very seriously — their disclaimer that the report does not constitute
medical advice.  (Additional disclaimer: this blog — style="font-style: italic;">any blog, for that
matter — does not constitute medical advice.)  Rather, it is
one source of information to be considered among others.

Comments

  1. #1 Hyperion
    December 2, 2006

    The one concern I’d have with this report, and I’m probably not the first to say this, is the possibility that it might influence insurance coverage.

    After all, the last thing insurance companies need is more excuses to avoid paying for psych meds, and you can just see some barely competent beancounter looking at this and deciding that they won’t cover the more expensive drugs when these cheaper ones are listed as being as effective. Then again, in my experience insurance companies will just make up evidence if it’s not available, so this probably won’t change things much.

  2. #2 Daniel Haszard
    December 2, 2006

    Eli Lilly zyprexa cost me $250.00 a month supply and has up to ten times the risk of causing diabetes and severe weight gain.

    Nervous investors watch Eli Lilly shares drop $2.80 post election.

    My issue is Zyprexa which is only FDA approved for schizophrenia (.5-1% of pop) and some bipolar (2% pop) and then an even smaller percentage of theses two groups.

    So how does Zyprexa get to be the 7th largest drug sale in the world?
    Eli Lilly is in deep trouble for using their drug reps to ‘encourage’ doctors to write zyprexa for non-FDA approved ‘off label’ uses.

    The drug causes increased diabetes risk,and medicare picks up all the expensive fallout.There are now 7 states (and counting) going after Lilly for fraud and restitution.

    Daniel Haszard

  3. #3 Joseph j7uy5
    December 3, 2006

    Insurance companies are evil.

    There are also studies that show a reduction in hospitalization with use of the more expensive drugs. Anyone who looks at the literature as a whole, not just the studies cited in the Consumer Reports report, would have to conclude that it would be a mistake to limit the insurance coverage of the drugs so drastically.

    Another thing is this, and this is one of the points in the CR report: if someone is on a drug and is doing well, it is a big mistake to take them off. I can pretty much guarantee that if insurance companies dropped the newer drugs from the formulary, there would be a lot of hospitalization and it would cost a fortune.

    Furthermore, the studies that show equivalent effectiveness refer to populations, not individuals. Within any population there are going to be people who do not respond to any one drug, or class of drugs. So an insurance company pretty much has to cover at least some of the drugs in each family.

    An although the newer drugs are thought of collectively as “atypicals,” they are all quite different, pharmacologically. Therefore, you can’t think of them as comprising a family of similar drugs, like, say, the SSRIs.

  4. #4 Greg P
    December 3, 2006

    While I suppose there is some kind of general sense that drug companies make new drugs only so that they can make money, the reason to a large extent has to do with the fact that existing drugs have problems. Yes, they may handle the primary diagnosis for which they were created, but they may be difficult to adjust, there may be long-term problems of one kind or another, and while there may be good control of whatever they were prescribed for, the patient may have a subjective ill feeling that leads to noncompliance.
    Older drugs, and not just older antipsychotic drugs, typically have a number of actions on the body, but in many cases the newer drugs may have more selective effects, and therefore cause fewer side effects or interactions with other medications.

  5. #5 stumpy
    December 5, 2006

    Keep it in mind, and never forget: A cynic is someone who knows the price of everything, and the value of nothing (thanks, Oscar Wilde). But also bear in mind that, if it’s true that insurance companies are evil, it’s equally true that big pharmaceutical manufacturers (including my homestate Eli Lilly people) are evil. Our job, as physicians trying to relieve suffering — and do no harm — is to match the correct medication to the patient. Sometimes there is no correct medication; it’s like the U.S.’s choices in Iraq, and amounts to choosing the least bad option.

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