Friday, July 10, 2009

The High Price of Sanity: What Antipsychotics Cost

When I was in medical school, there were these medications that were used to treat hallucinations and delusions (what we psychiatrists call "psychosis") and sometimes extreme agitation. They were the neuroleptics, and they worked: medicines like thorazine, and haldol, and mellaril, and navane. Oh, and like prolixin, too. They worked, but they came with a horrible stigma and lousy side effects. Some people tolerated them with no problems, some people even preferred how they felt when they were on them, but a lot of people found them to be pretty awful. Some made patients very tired -- this is why they are also referred to as major tranquilizers. Others were less sedating, but they made people very stiff: a side effect called Parkinsonism because they chemically gave people a temporary state similar to Parkinsons' Disease. You can sometimes look at someone and know they are on medication, and this is never good. And sometimes they caused a permanent, irreversible movement disorder called Tardive Dyskinesia. Okay, so people really don't like taking these medications, and sometimes they can be fine-tuned with other medications to halt the side effects, but they come with a price.

By the time I was a resident, the new generation of antipsychotics had come along. Risperdal, Zyprexa, Geodon, Abilify, Seroquel, Invega, the list marches on. These medications also worked and people didn't mind taking them (...okay, some people didn't mind taking them). They are also used for mood stabilization, to calm agitated states, for mania, as augmentation for depression, and sometimes for sleep. They aren't addictive, they aren't as stigmatized, and the immediate side effects aren't so troublesome. It's much easier to get patients to consider taking them and my experience is that in the short run, they help a lot of people feel better and function better. The down side has been that in some people they cause weight gain, diabetes, and hypercholesterolemia/hyperlipidemia. We don't seem to know who will have these problems (clearly, not every one does) and sometimes people are so sick without them that we're stuck fixing one disease while contributing to, or causing, another, and that needs treatment, too. And did I mention that these medications cost a fortune. If that's not enough, we have to order regular blood tests to monitor for the problems they cause, and patients may need more and expensive medications to treat the conditions the medicines cause.

So how much does it cost to stay sane? The state of Maryland, apparently, spends $80 million a year for atypical antipsychotics (these newer medications) for patients with Medicaid, and I suppose for uninsured patients in the hospital. This doesn't count the patients who self-pay, or have private insurance, or who get samples from their doctor, or who have Medicare. So the cost of keeping my state sane is pretty high. So far, only one of these medications, risperidone, is available in a generic.

Okay, so I price-shopped. I called some pharmacies, and here's the price for 30 pills. Remember, some people take higher doses-- I priced middle-range doses-- and some patients take several pills a day:

DRUG Walgreens   CVS   Sam’s Club Independent
Risperidone (Risperdal brand), 3mg $339 $385 $292 $295
Risperidone (generic), 3mg $170 $203 $150 $  46
Quetiapine (Seroquel brand), 25mg $  85 $103 $  82 $  97
Quetiapine (Seroquel brand), 200mg $265 $324 $262 $262
Haloperidol (Haldol brand), 5mg $  10 $  11 $    4 $  28
Aripiprazole (Abilify brand), 10 mg $449 $542 $440 $450

Hmmm, so there's a $3/pill differential for Abilify, depending on where you get it?
Oh, and I wondered about the generic risperidone--- $203 at CVS and $46.50 at a local independent pharmacy? I asked the pharmacist to check it twice, and then I called a second mom & pop pharmacy, and their price was just under $40. If you pay cash, it's worth shopping around. Are these the prices your insurance company pays? I doubt it-- they negotiate deals and have formularies. I asked how much the state pays for the medications for a patient with Medicaid, and none of the pharmacists I asked could tell said it was top secret. Okay.

One note on Haldol, the older generation medication-- I'm not sure if the $28 price was for generic or name brand, the others were all for the generic.


Marie said...

I'm amazed at the price difference for medications! When I lost insurance coverage for my meds, I shopped around and couldn't believe the cost difference.

1 month of Lexapro at Walgreens? $133.
The same 1 month supply at Costco? $87. That's a $46 difference for the exact same pills.

SteveBMD said...

Here's another shocker:

Lamictal (name brand):
~$250/month (everywhere)

Lamotrigine (generic):
~$240/month (almost everywhere)
$25/month (Costco)

Yes, a full order of magnitude!

Anonymous said...

I take Zyprexa Zydis - the melt-in-your-mouth version of Zyprexa which I tolerate better then regular Zyprexa (no weight gain or cravings) and the retail price for sixty 5mg pills (a one month supply) is a whopping $741.99.

Luckily I pay only $50 of that.

Fat Doctor said...

Any wonder why our national cost of healthcare is through the roof?

Roy said...

Correction: Medicaid does not pay hospital costs of meds for the uninsured. Well, not directly. Maryland has a unique regulated hospital fee structure that spreads the cost of uninsured fees across all other insured payors. So, all insured people pay the cost of treating uninsured pts (hospital-based care only).

God said...

Let's play nice now that we can comment anonymously.

Retriever said...

Oh, the great tax on people who pay for health insurance to subsidize those who can't or won't...I remember that in our state. When my spouse was unemployed and we scraped together the money for COBRA, we had hundreds of dollars tacked onto the bill when our baby was born "for the uninsured". Insurance wouldn't pay it, we had to fork over the cash. Our reaction was not printable....

Years later, in another state, my brother chose to go bare without health insurance so that his wife could drive a Mercedes. When he got a heart attack aged 45, the taxpayers in his state paid out 400,000 in the first few months for his care in a vegetative state (he ultimately died). The wife may still be driving the car...

With us, CVS is more expensive also. Consider also that most people taking these are usually taking other meds as well, and that other people in the family may have a prescription or six between them. In addition consider that many people who have health insurance have moved in recent years from paying 10-30 dollar copays per scrip to paying a percentage of the cost, and/or having to pay the full price if their insurance will only cover a generic but a patient may only do well on the brand. Or may only be able to swallow a medication in a particular form that costs more....

Consider also that it is such a miracle when one finally finds a medication that stabilizes a person, and that has bearable side effects, but if cost becomes an issue, either the person (if self-paying) or insurance or Medicaid may say "Nah, gotta take the cheaper one..." How much does a relapse cost?

On weight gain, tho Zyprexa's awful effects are immediately apparent, some of the other ones like Risperdal appear initially to have less effect in the short term but, over the long run, often cause a steady upward path (which is probably part of the whole inducing diabetes?) Appetite, satiation, metabolism, and carbohydrate cravings are affected.

Kaitlyn said...

It may just be the area I'm in and where I work, but most of the patients (90%) receiving antipsychotics are Medicaid or Medicare (disability). The state pays whatever it wants. For example, on a $2000 rx, they might pay $800.
Likewise, private insurance companies pay whatever they like. Very similar to how other health care providers are reimbursed.

a psychiatrist who learned from veterans said...

To reduce cost I have combined cyproheptadine, a drug I originally took an interest in for nightmares, with the typical neuroleptics; both are generic. Cyproheptadine (Periactin) has the 5HT2 receptor blocking action which Risperdal introduced to us as the mechanism of atypicality, a consequent effect on dopamine output in the substantia nigra. I use Periactin 4 mg 1-2 at night; there was a letter about such use in Archives of General Psychiatry perhaps 6-8 years ago.

Anonymous said...

Imagine then, a resourceful person, who, has recently lost health insurance, and due to state cuts, her therapist and psychiatrist, while in current recovery for an eating disorder, along with the typical depression and anxiety.

She's not sick enough to receive medicaid, can only work part-time due to college, and is now facing around $560 for medications.

The county hospital will provide prescriptions, involving a 6 hours wait, to be asked 5 questions, given a script and sent for another 2 hour wait to drop-off at the pharmacy. Pick-up, try later - but she's the lucky one.

What happens to her as she has to pick which medications to take? There's no one to help her taper or try other medications and monitor reactions.

It's sad and frustrating and scary for the observers.

Anonymous said...

There is very good reason for these outrageous expenses; most psychiatrists are under the impression that any patient who refuses to take antipsychotics, even one with ho history of psychosis, must be an addict. Since there are "so few side effects from atypical antipsychotics" and they can do "all the same things as any benzodiazapine, without being addictive," apparently EVERYBODY needs these drugs! A great deal of patients don't even know what the drugs are -- when asked why she was on Abilify, one patient responded "it's an antidepressant."

Anonymous said...

I'm confused. You advocate use of low-dose Seroquel as a sedative. Correct me if I'm wrong, but the mechanism of action in Seroquel's sedative effect is histamine H1 antagonism, just like diphenhydramine. (Or perhaps more accurately, inverse agonism, I'm not completely clear on the difference, but it's a moot point anyways, since that's true for both.) And the low doses of antipsychotics used for this purpose have no actual effect as an antipsychotic, only as a sedative. So why is a $100 bottle of Seroquel preferable to a $2 package of Benadryl?

Kaitlyn said...

The majority of drug companies have patient assistance programs for the uninsured. Definitely worth checking out for those who are in the low and middle-income ranges. Some websites:

DHS said...

For what it's worth, Australian costs of these drugs (and these are private costs, if the Health Insurance Commission doesn't pre-approve prescriptions on a separate pad:
(Prices are in AUD, which is similar to CAD and a little less valuable than USD)

Risperdal 3mg x 60 $174 (unsure about generic pricing)
Seroquel 200mg x 60 $190
Abilify 10mg x 30 $150

(This is also the pricing for non-citizens/permanent residents).

Prices obtained from, and are approximately the official price negotiated between the govt and pharma (published in MIMS, no free online access).

Roy said...

Anon is correct; most of low-dose Seroquel's effect comes from antihistamine property. I would rather try diphenhydramine (Benadryl) or hydroxyzine (Vistaril, Atarax) than Seroquel for the group of pts Dinah describes.

Also, no, most psychiatrists do not think that atypical antipsychotic refusers are addicts.

Dinah said...

Hmmm. I generally do try visteril first, and while it occasionally works, for whatever reason, Seroquel (or other atypicals) seem to work better for severe agitation (and yes, sometimes people with severe agitation also take cheaper benzos as well-- funny but they don't work for everyone either). The atypicals seem to have some mood stabilizing effect for at least some of the people some of the time, that is not simply sedation. Benedryl helps some people sleep, but I haven't found that it helps so many people with notable psychiatric distress who are already on other medications.
If it's the only therapeutic issue here is the anti-histimic side effect of low-dose seroquel, then it makes no sense that clinically some people respond to it when they don't respond to Benedryl.

Personally, I believe there is some power to they "prescription" medication and part of why I use Visteril rather than benedryl....people in distress are often not open to hearing they should take a cheap otc med, they've often tried it for sleep already or allergies, and feel it's ineffective. Otherwise, it's a great, and cheaper, choice and if it works, it's what should be used.

a psychiatrist who learned from veterans said...

An inverse antagonist lowers the nonstimulated activity of the receptor neuron. For a histamine responsive neuron this would mean that a typical antihistamine like Benadryl would just block any stimulation by ambient histamine. The nerve would have a natural firing rate which could be raised by histamine stimulation (which this antihistamine would block). An inverse antagonist however would reduce the firing of this neuron below its nonstimulated state. In that sense, if as anonymous said July 15, Seroquel is an inverse antagonist, then it is a 'super' antihistamine. See my letter in J. Clin. Psychiatry, vol 68 no. 6 about side effects of Geodon (ziprasidone) for further lead in to the topic,

Anonymous said...

-1 talking $ is bad manners

Barbara A said...

Barbara A. I'm amazed by the number of anonymous comments. Indeed, there still exists a stigma about mental illness.

I might suggest the possibility of refering to orthomolecular psychiatry as a treatment modality. I certainly do not have access to information about the efficacy of this treatment with regard to the broad spectrum of mental illnesses, but I think it might be a promising avenue to search.

Google orthomolecular psychiatry.