Several health care payers and health maintenance organizations have produced more explicit guidelines for the choice of antidepressant and antipsychotic medications. These range in scope from designations of preferred medications to more comprehensive sets of guidelines for the management of these illnesses.
Among the payers interviewed in this study, there was no consensus on the choice of recommended first line agents. In general, however, payers are more concerned about managing antidepressant utilization than they are about managing the utilization of antipsychotics. This is largely because the antidepressants (in particular the SSRIs) have a far greater potential for misuse, including their use in the promotion of weight loss, performance enhancement (the "better than well" effect), and the treatment of melancholy that does not constitute depression.
In designing treatment guidelines/disease management, most MCOs try to integrate pharmaceuticals with non-pharmacotherapies. Plans may recommend choice of agents by brand, drug class, dose, duration of therapy, side effects, and required follow-up care. Although distribution of guidelines is not common, one of the five plans interviewed reported distributing these materials to the patient as well as making them available for sale to other health plans. The focus of the program at one large, group-model HMO was more one of physician monitoring and education. This MCO has implemented guidelines to insure better management of depressed patients.
Another large, group-model HMO recommends that either a TCA or an SSRI is an appropriate first-line choice for an antidepressant, leaving the option to the physician. Another group-model HMO admitted to recommending the least expensive agent available, whether it was an SSRI or a TCA.
First-line choices for antipsychotics likewise vary by payer, although few actively promote the use of atypical over typical antipsychotics. One HMO reported promoting the use of typical antipsychotics first-line even though prior authorization requests for atypicals are never denied.
Several PBMs are in the process of developing diagnosis and treatment guidelines (e.g., disease management, preferred drug list). Several reported using the AHCPR guidelines for depression, while others reported following those of their MCO clients. One large PBM has organized an outcomes research division to inform its development of guidelines for the diagnosis and treatment of depression. On the other hand, another large PBM feels that its role in the treatment selection should be minimal and that guidelines should be as general as possible. PBMs reported marketing the guidelines and programs they develop to providers, consumers, and employer and MCO clients.
Often, treatment guidelines published by PBMs have embraced the most up-to-date pharmacotherapies. For example, treatment guidelines published by the pharmaceutical benefits manager PCS state that SSRIs are the drugs of first choice for the treatment of depression, citing less risk of overdose, decreased side effects, increased patient compliance, and demonstrated cost effectiveness. At the time of publication, the national formulary of PCS included all five SSRIs currently available in the US. These guidelines also recommend atypical antipsychotics as first-line therapy for "patients experiencing psychotic episodes in which both positive and negative symptoms are apparent."37 PCS has also implemented formal disease management programs for both depression and schizophrenia.
Pharmaceutical manufacturers play a role in developing treatment guidelines, although these generally cannot focus on their product or pharmacotherapy alone. Rather, they aim for broad coverage of a class of drugs and integration of pharmaceuticals into overall treatment of the disease. One manufacturer stated that most schizophrenia guidelines have atypicals as first-line. Manufacturers may also assist academic institutions with the development of treatment guidelines. This was particularly true for schizophrenia guidelines, such as TMAP.
Employers do not generally concern themselves with the selection of preferred or covered pharmaceutical agents. Likewise, they do not develop or adopt treatment guidelines or disease algorithms for depression, bipolar disorder or obsessive-compulsive disorder. However, health benefits consultants report that they generally encourage employers to cover the most up-to-date pharmacotherapies for mental illness. Only one employer interviewed reported implementing a disease management program for depression, although others expressed interest. This program was a PBM-sponsored program monitored through the PBM contract.
Surprisingly, most BHMCOs are not involved in the writing of clinical practice guidelines for the treatment of mental illnesses. Magellan, the largest BMHCO, recently announced a program to produce general guidelines on the use of antidepressant medications as a component of comprehensive mental health care. However, these guidelines will focus on prescribing practices and appropriate use. They will not endorse specific pharmaceutical agents. The guidelines are being developed within a 3-year program designed to identify prescribing patterns for antidepressants. These guidelines will develop an independent Expert Consensus Panel Guidelines that specify a standard of care. The program will also analyze prescribing data to identify the appropriateness of prescribing in current practice. Finally, the program will develop an educational program to instruct physicians on appropriate prescribing protocols. These guidelines are being developed in collaboration with Eli Lilly.38