We know one thing for sure that’s typical for the atypical (or second generation) antipsychotics. They’ve caught on like a house on fire.
The atypicals are the top-selling class of drugs today, with revenues in 2010 of about $14.6 billion and $18.2 billion in 2011. They have even surpassed the blockbuster statins that treat high cholesterol (think Lipitor) and drugs that treat reflux (yes, even the Purple Pill), which seems almost inconceivable, given how many people take the take high cholesterol and reflux medicine..
In fact, the fifth and sixth best-selling prescription pills currently in the U.S. are two atypicals: Abilify and Seroquel. Does anyone else but me find this completely astonishing? (Of course, if you saw the price tag these two carried, you’d understand how they worked their way to the top. In fact, fewer prescriptions are written for Abilify, but it beats out Seroquel in revenue, due to its staggering cost.)
The number of scripts of atypicals per year grew to 54 million in 2011 from 28 million in 2001, an 93% increase.
And their usage strays frequently from their original FDA approvals, which are for schizophrenia.
Use of antipsychotics for illnesses without FDA approval increased from 4.4 million in 1995 to 9.0 million in 2008–and continues to go up with each passing year.
Interestingly, from 1995-2008 there was a 45% decrease in the proportion of the atypicals used for schizophrenia–the original source of their approval–and a seven-fold increase in use for bipolar disorder, which then made up one-third of all use of the atypical antipsychotics.
“Trends in Use of Second-Generation Antipsychotics for Treatment of Bipolar Disorder in the United States, 1998–2009,” just published in this past month’s Psychiatric Services, illuminates how quickly and radically the shift in prescribing patterns in favor of the atypicals has been vis-a-vis bipolar disorder.
Researchers studied data from a representative audit of 4,800 office-based physicians in the U.S.
Their unit of analysis was what they termed the ‘treatment visit,’ which they defined as “a visit in which bipolar affective disorder was diagnosed and treated with one or more pharmacotherapy.”
Their findings might surprise you.
Note the following:
- The percentage of treatment visits which resulted in an atypical being prescribed for bipolar disorder increased from 18% in 1998 to 49% in 2009, an increase of 167%.
- In the 12 months following approval of Zyprexa, a fairly early and originally quite popular atypical, its use increased by 92%, and use of other atypicals increased by 42%.
- Treatment visits where an atypical was used as the only pharmacological treatment (lithium be damned) increased from 7% in 1998 to 27% in 2009.
- And–get this–the percentage of visits in which an atypical was used with a mood stabilizer went from 77% in 1998 to 47% in 2009. That means that by 2009 more than half (53%) of visits involving an atypical did not include a mood stabilizer.
And that doesn’t begin to address what goes on in other parts of the world.
Atypical antipsychotics are the most expensive drugs prescribed for bipolar disorder in Europe, too, contributing nearly three-fourth of the revenues of the European bipolar disorder therapeutics market, which was valued at $1.20 billion in 2011.
Nor does it address the pediatric market. researchers found that nearly 50% of children treated as inpatients for psychotic and mood disorders are given atypical antipsychotics.
Outpatient visit rates increased radically early on, as well, with those for atypicals in patients under 20 quadrupling between 1997 and 2002.
Since 1993, the rate of antipsychotic drug prescribing to children increased 8-fold, and prescriptions for teens quintupled and in adults nearly doubled. That data almost solely addresses the atypical antipsychotics.
We may not fully know how superior the atypicals are to the first-generation antipsychotics, we may not be able to predict how many more atypicals will be coming up drug-makers’ pipelines, we may not have insight into how the patent cliff will affect the makers of these treatments (Zyprexa, Risperdal and Clozaril are all already off patent)–but we surely do know that atypicals have succeeded in bringing in revenue beyond what must have been the wildest expectations of the first scientist who thought: “What if we created a molecule that would treat schizophrenia, without causing EPS symptoms? Maybe that would that change the world of psychiatry.”
Maybe, indeed.
Glennis
October 5, 2012
mind boggling.
candidaabrahamson
October 5, 2012
Isn’t it? Outselling the statins, with King Lipitor? Truly astounding.
Natasha Tracy
October 5, 2012
Actually, to be clear, several antipsychotics are FDA approved for uses other than schizophrenia.
Aripiprazole (Abilify) is approved for mania, mixed states and maintenance treatment in bipolar (and as an add-on for depression, I believe)
Ziprasodone (Godon) is approved for mania and mixed states in bipolar disorder
Quetiapine (Seroquel) is approved for mania and depression in bipolar disorder
And so on.
http://emedicine.medscape.com/article/286342-treatment#showall
So that explains, in large part, the dramatic increase in prescriptions. They have been shown very useful in both depression and bipolar.
- Natasha Tracy
- http://natashatracy.com
Rhona Finkel (@Abitofthisand)
October 5, 2012
You are correct as usual, Natasha, and I regret if I gave the impression that some of the atypicals [although not by all means all] were not approved for bipolar disorder. As I wrote on google+, I might even add Zyprexa in combination with Prozac, which is both approved and has been shown to be effective for bipolar depression.
I do still find it amazing how many people are treated with the atypicals as monotherapy, though, when they have bipolar, given the long-term effectiveness of the older mood stabilizers (yes, even the dreaded lithium), and am impressed with the marketing that has caused the drugs to be such a success, when their costs are astronomical.
Despite that, I remain very happy we have them around to treat both schizophrenia and bipolar disorder, often in very resistant situations.
Thank you as always for your insights.
billgncs
October 5, 2012
do you feel that this represents a true need, or are the drugs over-prescribed?
candidaabrahamson
October 5, 2012
Perhaps a bit of both.
billgncs
October 5, 2012
it is almost as if we are in a malaise of culture, and that at least some of the solution may be mechanical within how we are living.
ManicMuses
October 8, 2012
Very disturbing, indeed. Antipsychotics are powerful medications that, in general, are being misused and abused. Off-label use is running rampant and unchecked…particularly when it comes to using these drugs as a means of chemical restraint among children and the elderly. Even when used in the control of Bipolar Disorder, antipsychotics are noting to fool with. I’ve been ranting on my own blog about my trials and tribulations with being thrown into psychosis while trying to quit Abilify, and it’s important to note I never present any psychotic features before taking this drug.
Off-label use needs to stop. There needs to be a cold, hard look by the psychiatric establishment at the tendency to use this powerful medication as a go-to prophylactic instead of a treatment for a well-defined, serious condition that already includes psychosis. There is a dire need for further studies around psychosis associated with the use of antipsychotics. Physicians need to put down the prescription pads and drug company / drug logo-ed pens and be more responsible when prescribing this medication.
candidaabrahamson
October 8, 2012
I know–your experiences with Abilify have sounded very distressing. And there is, it’s true, much off-label use–but as Natasha Tracy points out, the a number of the atypicals are approved for other uses, particularly bipolar disorder. I have seen some amazing turn-arounds from them. I guess, as with all things, it takes a doctor who uses wisdom, restraint, and experience, to make sure they’re used properly.
sanford finkel
October 21, 2012
Indeed, the cost of these medications is exorbitant. Many without insurance cannot afford them. In some States, they are breaking the Medicaid bank.
At the same time, they are generally effective and offer a better side effect profile than the older antipsychotic medications.
In reviewing the statistics, it important to note that these drugs only began to come on the market around 1995, and some not till this century. So data looking at increases from 1998 are erroneous. Also, one of the key reasons that these medications are used more frequently for bipolar disorder is that the research shows that the atypicals are effective.
Rhona Finkel (@Abitofthisand)
October 23, 2012
Your points on both sides of the issue are well-taken, in that the medications are staggeringly expensive and are breaking the banks, but also that some are quite effective, without the EPS issue.
I appreciate your pointing out that the data timeline is exaggerated due to the choice of years of measurement.
Thank you, as always, for reading for for your astute comments.