The Paradox of Choice: When More Medications Mean Less Treatment

Dr Barkil-Oteo will be presenting on the topic presented in this article at the 2013 APA Annual Meeting, in a workshop titled “The Future Is Now: The Future of Psychiatry Through the Eyes of New Psychiatrists.”

This is an exciting time in health care, with a growing emphasis on patient-centered care that is driven by patients’ preferences.¹ There are many advances in pharmacology, innovative services, and new scientific knowledge in the field of mental health that should expand treatment options and help in individualizing treatment plans. However, there is a need to examine whether these developments will lead to empowering patients and expanding their options, or on the contrary, limiting them.

In particular, 2 problems persist in the treatment of severe mental illness that constitute a barrier to effective patient-centered care: excessive reliance on a limited number of antipsychotic medications at the expense of other effective treatments, and the underutilization of other evidence-based treatment options.

In 2009 Philip Wang, MD, PhD, current Deputy Director of the National Institute of Mental Health, and colleagues,²stated that while medically ill patients in the US receive the recommended care about half of the time, the corresponding rate for people with serious mental illnesses is no more than 1 in 4. At the same time, over the last 15 years, psychotropic medication use in general, and in particular the simultaneous use of more than 1 prescription drug, has increased, with little indication of concurrent changes in patients’ illness severity or comorbidity.³ In 2011 total spending on antipsychotic medications was $18.2 billion (the fifth most expensive medications class right after antidiabetics).⁴ This spending saw an increase of $2.1 billion from 2010, where the increase was only $1.5 billion from 2009. This demonstrates acceleration in spending on, and consumption of, medications. Eighty percent of the money was spent on only 3 antipsychotics (Abilify, Seroquel, and Zyprexa). Fifty-seven million prescriptions were filled in 2011, up 2.4% from the previous year, with over 60% filled for branded antipsychotic therapies, which stands in stark contrast with total medication sales, where 80% were generics.

The exorbitant cost of antipsychotic medications may change, given that 2 out of the 3 medications (Zyprexa and Seroquel) are in the process of becoming available in generic forms. However, there is no guarantee that the savings will be directed to other treatment modalities in mental health, and recent trends in the pharmaceutical industry indicate that the manufacturers of generic medications are consolidating: Such reduced competition could lead to sustained high prices for generics in the future. As of 2010, 4 manufacturers of generic medications control 47% of the US market.⁵ Moreover, the Supreme Court is hearing a case, Federal Trade Commission v. Actavis, where generic and brand-name drug companies will be on the same side.⁶ This case could validate payments by the makers of brand-name drugs to generic-drug companies for the purpose of keeping generic versions out of the market.⁷

Some evidence-based approaches to chronic mental illness (CBT groups for psychotic symptoms, supported employment, family psychoeducation, and supported housing programs, among others) are underutilized. For example, in the 1990s, the Schizophrenia Patient Outcomes Research Team (PORT) study found that patients were receiving only 10% to 46% of the approved treatment interventions for schizophrenia, and later studies confirmed these results.^8,9 As reported by Drake and colleagues,¹⁰ constraints on mental health spending from Medicaid and state general funds reduced access to other evidence-based services, such as housing, vocational training, and case management programs. These budget cuts, coupled with increased spending on new expensive medications, have contributed to inadequate delivery of effective treatments. Such situations not only limit the basic right of choice for patients, but also increase the cost of services, concentrating treatment in few interventions of limited effectiveness.

Limited treatment choices jeopardize our ability to meaningfully include people in deciding their treatment. The values of people with mental illness cannot be incorporated if they don’t have a choice of treatment because in many cases they are offered few highly similar options. A meaningful choice experience should include options that are significantly different but complementary; deciding between 2 similar options provides only the illusion of choice. Instead, the process should be based on a collaborative approach, one balanced with the provision of informed choices and the offer of all evidence-based alternatives. Persons with mental illness, like every member of society, have the right to determine the direction and nature of any medical intervention, with providers occupying consultative and supportive roles.¹¹

Psychiatrists should be aware of the unintended consequences that may result from current patterns of spending in the mental health sector. Mental health professionals should advocate for evidence-based, rational use of medications (both generic and brand label) to encourage the most efficient use of resources. In a discussion of evidence-based practices in mental health, Essock and colleagues¹²urged mental health practitioners proactively to enjoin funding sources to withdraw money from ineffective traditional services that lack evidence and do not meet the needs or preferences of patients and their families: “Waste, rather than a different stakeholder group, is the common enemy, along with the inadequacy of current resources. Rather than fighting over limited dollars available for innovative services, practitioners should fight to use well whatever resources are available and end ineffective services.”¹²

People do not survive on antipsychotics alone. Rather, they are sustained by positive coping mechanisms, a home, a job, and meaningful social interactions. When served with alternatives, people will not accept interventions that they do not want. Provision of new, expensive medications as the sole option for treatment should not take the place of delivering comprehensive care. In an era of patient-centered medicine, patient choice should be highly valued. The right to receive all evidence-based interventions, both pharmacological and psycho-social, must be assured. In order to facilitate a broader range of medical and psychosocial interventions, psychiatrists should play 2 important roles in the current mental health system: as guides in the selection of evidence-based treatments that match patients’ values; and as advocates for the most efficient use of resources.