Access and Utilization of New Antidepressant and Antipsychotic Medications. The Use of New-Generation Antidepressants in Medicaid Grew Dramatically Between 1995 and 1998

01/01/2000

​Exhibit VI-16 depicts national trends in prescriptions for antidepressants in Medicaid between 1995 and 1998. Overall, prescriptions for antidepressants increased substantially in this period. Antidepressant prescriptions increased from 13.7 million in 1995 to 19.3 million in 1998, an increase of over 40%. Exhibit VI-17 reports trends in Medicaid expenditures for antidepressants between 1995 and 1998. Total expenditures increased steadily from $500 million in 1995, to $630 million in 1996, to $760 million in 1997 and to $985 billion 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.

Prescriptions increased for every class of antidepressant except for TCAs and MAOIs. These trends are shown in Exhibit VI-18. Prescriptions for sertraline and fluoxetine increased by approximately 45% each, from already substantial bases in 1995. 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%. Fluvoxamine experienced more than a four-fold increase in prescriptions from 1995 to 1998 (72,885 to 306,967, an increase of 321%) while bupropion prescriptions increased 264%. Prescriptions for venlafaxine doubled over the same period. During the same period, prescriptions for TCAs fell from 6 million prescriptions in 1995 to 5 million in 1998.

Exhibit VI-13. Market Share of Antidepressant Classes in 45 Medicaid States, 1998. Total Prescriptions = 19 Million

Exhibit VI-13. Market Share of Antidepressant Classes in 45 Medicaid States, 1998. Total Prescriptions = 19 Million

Source: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1998. 45 States Reporting.

Exhibit VI-14. Market Share of Antidepressant Classes in 45 State Medicaid Programs, 1998. Total Expenditures = $985 Million

Exhibit VI-14. Market Share of Antidepressant Classes in 45 State Medicaid Programs, 1998. Total Expenditures = $985 Million

Source: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1998. 45 States Reporting.

Exhibit VI-15. Share of Medicaid Antidepressant Prescriptions and Expenditures by Class, 1998

  Prescriptions Expenditures
Class Number
(000s)
% of Medicaid
Antidepressant Rx's
$
(Millions)
% of Medicaid
Antidepressant $
Fluoxetine 2953 15% $288 29%
Fluvoxamine 307 2% $34 3%
Paroxetine 2925 15% $199 20%
Sertraline 3007 16% $214 22%
Bupropion 1054 5% $64 7%
Venlafaxine 663 3% $45 5%
Nefazadone 697 4% $33 3%
Mirtazapine 436 2% $29 3%
Trazodone 2215 11% $22 2%
MAOIs 18 0% $1 0%
TCAs 5055 26% $54 5%
All Antidepressants 19,354 100% $985 100%

Source: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1998. 45 States Reporting.


Exhibit VI-16. Antidepressant Prescription Trends in Medicaid, 1995-1998. Total Prescriptions in Thousands

Exhibit VI-16. Antidepressant Prescription Trends in Medicaid, 1995-1998. Total Prescriptions in ThousandsSource: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1995-1998. 46 States reporting, 1995-1997, 45 States Reporting, 1998.

Exhibit VI-17.Antidepressant Prescription Trends in Medicaid, 1995-1998. Expenditures in Millions

Exhibit VI-17.Antidepressant Prescription Trends in Medicaid, 1995-1998. Expenditures in MillionsSource: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1995-1998. 46 States reporting, 1995-1997, 45 States Reporting, 1998.

The data in Exhibit VI-18 also show that since the introduction of nefazadone in 1995 and mirtazapine in 1996, there have been steady increases in the number of prescriptions for these agents. By the end of its second year on the market, nefazadone claimed 697,000 prescriptions, nearly 4% of the market, while mirtazapine claimed 436,000 prescriptions or almost 3%. In addition, in its first quarter on the market (Q4, 1998) citalopram accumulated 22,544 prescriptions. Industry reports have indicated that citalopram claimed 10% of the SSRI market by November 1999, making it the forth most successful pharmaceutical launch in history43 It is unclear how citalopram has been received by Medicaid, however, as 1999 data was not available at the time of this study.

Exhibit VI-18. Antidepressant Class Prescription Trends in Medicaid 1995-1998. Total Prescriptions in Thousands

Exhibit VI-18. Antidepressant Class Prescription Trends in Medicaid 1995-1998. Total Prescriptions in Thousands

Source: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1995-1998. 46 States reporting, 1995-1997, 45 States Reporting, 1998.

As shown in Exhibit VI-19, expenditures for paroxetine increased nearly three-fold (an increase of $128 million over four years), while expenditures for fluoxetine increased 73% ($120 million), and expenditures for sertraline increased 64% ($84 million). Expenditures for venlafaxine, bupropion, and nefazadone enjoyed large percentage increases over these years, but, as lower-volume antidepressants, the total reimbursed for these agents was not nearly as large as the total for the three leading agents. Expenditures for bupropion increased nearly 3-fold between 1997 and 1998, likely reflecting increased use of this agent as an aid to smoking cessation (a new indication for bupropion in 1997). In terms of dollars reimbursed, only TCAs fell significantly, from $77 million in 1995, to $67 million in 1996, to $54 million in 1997 and 1998.

As the total amount reimbursed for antidepressants increased steadily over this period, the market share of each of the antidepressant classes remained fairly constant during the years 1995 to 1998. With the largest share of the market, fluoxetine's share fell somewhat: from 33% in 1995 and 1996 to 32% in 1997 and to 29% in 1998. Likewise, sertraline, accounting for the second largest share of expenditures, also saw its share fall slightly, from 26% in 1995 to 22% in 1998. Expenditures for TCAs' fell as a percentage of total costs as well: from 15% in 1995 to 5% in 1998. Among the high-volume antidepressants, only paroxetine experienced an increase in terms of total share of Medicaid expenditures. Expenditures for paroxetine increased from 14% of total in 1995 to 20% in both 1997 and 1998. Bupropion, while beginning from a much lower dollar base in 1995, saw its Medicaid market share rise from 2% in 1995 to 6% in 1998.

Exhibit VI-19. Antidepressant Class Prescription Trends in Medicaid, 1995-1998. Total Expenditures in Millions

Exhibit VI-19. Antidepressant Class Prescription Trends in Medicaid, 1995-1998. Total Expenditures in MillionsSource: The Lewin Group analysis of HCFA(now known as CMS) Medicaid Drug Rebate Program Data, 1995-1998. 46 States reporting, 1995-1997, 45 States Reporting, 1998.