Access and Utilization of New Antidepressant and Antipsychotic Medications. C. Utilization of Newer Antidepressant and Antipsychotic Medications by State Medicaid Programs 1995-1998

New generation antipsychotics and antidepressants have been accepted into common use within Medicaid programs.

• In 1998, 51% of the 11 million Medicaid antipsychotic prescriptions were for atypicals.
  • In contrast, atypicals accounted for 17.5% of 9.1 million Medicaid antipsychotic prescriptions in 1995.
• In 1998, 62% of the 19 million Medicaid antidepressant prescriptions were for new-generation, branded antidepressants.
  • In contrast, new generation antidepressants accounted for 44% of 13.6 million Medicaid antidepressant prescriptions in 1995.

The introduction of atypical antipsychotics and new-generation antidepressants has been accompanied by a growth in the total market for antipsychotics and antidepressants in Medicaid.

• The growth in both number of prescriptions for and cost of antidepressants and antipsychotics outpaces that of the aggregate by more than 2-fold.

Antidepressants and antipsychotics account for nearly 9% of Medicaid pharmaceutical prescriptions and nearly 19% of Medicaid pharmaceutical reimbursements.

• Although the number of all prescriptions (i.e., from any therapeutic category) reimbursed by Medicaid has remained relatively constant between 1995 and 1998, expenditures have increased by over 40%.
• Prescriptions for antipsychotics grew 11% between 1995 and 1998 while expenditures increased by more than 160%.
  • Total Medicaid spending on antipsychotics exceeded $1.3 billion in 1998.
  • Uptake of atypical antipsychotics is driving pharmacy costs for this class.
• Prescriptions for antidepressants grew 40% between 1995 and 1998 while expenditures increased by approximately 96%.
  • Total Medicaid spending on antidepressants reached $985 million in 1998.
  • Increased numbers of prescriptions together with uptake of new-generation antidepressants is driving pharmacy costs for this class.

New-generation antidepressants and antipsychotics have been accepted into common use by Medicaid programs at about the same rate and to the same extent as other innovator drugs.​

• Utilization of Antipsychotics

  • In 1998, 51% of all Medicaid prescriptions for antipsychotics were for atypical antipsychotics. Expenditures on atypicals accounted for 89% of total spending on antipsychotics.

    • In 1998, Medicaid programs in 45 States analyzed paid for nearly 11 million prescriptions for antipsychotics.
      • Phenothiazines accounted for the largest share of antipsychotic prescriptions, with approximately 3.0 million prescriptions, or a 26% share.
      • Risperidone ranked second in number of prescriptions (2.8 million, 25%).
      • Olanzapine ranked third in number of prescriptions (2.2 million, 20%).
    • These 11 million prescriptions corresponded to expenditures of $1.3 billion.
      • Olanzapine accounted for the largest share of spending for antipsychotics at $536 million (42%).
      • Risperidone ranked second at $395 million (31%).
      • Clozapine accounted for the third largest share of expenditures, $172 million (14%).

    The use of atypical antipsychotics in Medicaid has grown dramatically since 1995. Concomitantly, the use of antipsychotics as a class has grown by 20% since 1995.

    • Medicaid antipsychotic prescriptions rose from 9.2 million in 1995 to 11 million in 1998, an increase of nearly 20%.
      • It appears that the introduction of atypical antipsychotics did not merely replace older therapies, but instead expanded the market for use of these agents as a category.
        • Medicaid prescriptions for risperidone increased from just over 1 million in 1995 (12% of total) to nearly 2.8 million in 1997 (25% of total).
        • Medicaid prescriptions for olanzapine have risen from 43,000 prescriptions in 1996 (0.5%) to over 2.1 million prescriptions in 1998 (20%).
        • Prescriptions for oral haloperidol decreased from 2.1 million in 1995 (23%) to 1.6 million in 1998 (18%).
        • Prescriptions for phenothiazines decreased from 4.2 million in 1995 (47%) to just under 3 million in 1998 (27%).
      • This trend of increasing numbers of antipsychotic prescriptions may indicate that more patients are willing to use the newer agents.
      • This trend may also reflect increased use in the management of other diseases, such as the behavioral disturbances associated with dementia.

    Expenditures on antipsychotics have vastly outpaced the growth in number of prescriptions.

    • Total Medicaid prescriptions for antipsychotics increased from 9.2 million in 1995 to nearly 11 million in 1998, an increase of 20%.
    • Total expenditures increased from $484 million in 1995 to $1.3 billion in 1998, an overall increase of 160%.

    In several high-volume States (FL, IL, MA, MD, MI, PA) risperidone has become the most frequently prescribed class of antipsychotic, outpacing the national averages.

    The uptake of newer antipsychotic agents into Medicaid immediately post-launch has been rapid.

    • From launch in the 4^th quarter of 1996, olanzapine gained 8% market share within four full quarters of marketing.
      • At the end of the second full year on the market, olanzapine attained a market share of 16%.
      • The number of olanzapine prescriptions more than doubled in the second year on the market.
    • From the time of the launch of olanzapine, risperidone market share increased from 17% to 22%
      • During this same period the number of risperidone prescriptions increased nearly 50%.
    • The uptake of quetiapine has been slow relative to olanzapine.
      • This difference may largely be attributed to market timing and marketing savvy.

• Utilization of Antidepressants

  • In 1998, 62% of antidepressant prescriptions were for new-generation, branded antidepressants.

    • Medicaid programs in 45 States paid for over 19 million prescriptions for antidepressants.
      • The selective serotonin reuptake inhibitors (SSRIs) comprised 48% of total antidepressant prescriptions in 1998.
        • Prescriptions for the three leading agents (fluoxetine, paroxetine, and sertraline) were nearly equal with approximately 3 million prescriptions each, or a 15-16% share each.
      • Tricyclic antidepressants accounted for 27% of total prescriptions
      • The four other new generation antidepressants (bupropion, mirtazapine, nefazadone, and venlafaxine) together accounted for 14% of prescriptions.
    • In 1998, Medicaid expenditures on antidepressants in these 45 States reached nearly 1 billion dollars ($985 million).
      • Together, fluoxetine, sertraline and paroxetine comprised over 70% of all Medicaid spending on antidepressant drugs in 1998 ($711 million).
        • Fluoxetine accounted for 30% ($288 million) of all Medicaid spending for antidepressants in 1998.
        • Spending for sertraline reached only $214 million (23% of all Medicaid dollars reimbursed for antidepressants in 1998).
        • Dollars spent on paroxetine comprised only $199 million (20% of all Medicaid dollars spent on antidepressants in 1998).
      • TCAs accounted for only 5% of all Medicaid dollars reimbursed for antidepressants ($54 million).
      • Other new antidepressants bupropion, venlafaxine, nefazadone, and mirtazapine together accounted for expenditures of approximately $173 million or 18% of total expenditures.

    The use of new-generation antidepressants in Medicaid grew dramatically between 1995 and 1998. As with antipsychotics, the growth in use of newer antidepressants rapidly outpaced the replacement of older agents.

    • Prescriptions for antidepressants increased from 13.7 million in 1995 to 19.3 million in 1998, an increase of over 40%.
      • Sertraline prescriptions increased from just over 2 million in 1995 to just over 3 million in 1998.
      • Fluoxetine prescriptions increased from just over 2 million in 1995 to just fewer than 3 million in 1998.
      • Paroxetine prescriptions increased from 1.2 million in 1995 to 2.9 million in 1998, an increase of 130%.
      • Prescriptions for TCAs fell from 6 million prescriptions in 1995 to 5 million in 1998 -- a 20% decrease.

    Medicaid expenditures for antidepressants outpaced the rate of growth in number of prescriptions between 1995 and 1998.

    • Total expenditures increased from $500 million in 1995 to $985 million in 1998--an average increase of 25% per year, and an overall increase of 96%.
      • Much of this increase can be attributed to the steady, yet significant rise of the three leading SSRI antidepressants.
        • Expenditures for paroxetine increased nearly three-fold (an increase of $128 million over four years.
        • Expenditures for fluoxetine increased 73% ($120 million).
        • Expenditures for sertraline increased 64% ($84 million).
        • Expenditures for TCAs fell from $77 million in 1995 to $54 million in 1998.

• Comparison of Psychotherapeutic Utilization with Utilization of Other Drug Classes

  • New-generation antidepressants and antipsychotics have been accepted into common use by Medicaid programs at about the same rate and to the same extent as other innovator drugs.

    • Newer antipsychotics appear to be proportionally more expensive than other new generation pharmaceuticals such as oral antidiabetics. Newer antidepressants appear to be roughly equivalent in cost to these other classes.