BEFORE THE EARLY 1990s the use of antipsychotics was largely reserved for adults with severe psychotic disorders. Since then, however, the newer atypical antipsychotics, widely considered as safer than first-generation (“typical”) antipsychotics, have transformed the landscape of antipsychotic treatment. Approval of risperidone in 1993 was followed by olanzapine (1996), quetiapine (1997), ziprasidone (2001), aripiprazole (2002), and paliperidone (2006). Having all but replaced previously approved antipsychotics, the atypicals are now prescribed to a much larger and more diverse clinical population.
Recent studies have raised concerns regarding the safety and effectiveness of atypical antipsychotics in this broadened population.1
Major gaps remain in the evidence base supporting treatment within these new subpopulations. Particularly scarce are comparative safety and effectiveness studies across individual atypicals.
Medications have historically been a relatively small component of mental health spending. By 2007, however, U.S. spending for antipsychotic medications was estimated at $13.1 billion, exceeded only by lipid regulators and proton pump inhibitors.2
As the predominant payers for people with mental disorders, public programs are disproportionately affected by the costs of atypical antipsychotics. In recent years, antipsychotics have become the most costly drug class for Medicaid programs, exceeding the runner-up (antidepressants) by a wide margin.3
Since the 2006 implementation of Medicare prescription drug coverage, antipsychotics have also become a major expenditure item for Medicare Part D.
In addition to cost concerns, states and other payers have been concerned about appropriate balancing of risks and benefits in prescribing, and about whether psychopharmacological treatment is consistently preceded by appropriate assessment and followed by adequate monitoring. Of particular concern has been increased use in two populations: children with behavioral problems and elderly people with behavioral symptoms of dementia. In this paper we examine antipsychotic treatment trends within these two populations.4