Update on Psychotropic Drug Prescribing in the United States

Our February, 2011 editorial in these pages analyzed psychotropic drug prescribing patterns in the United States for calendar year 2009.1 This analysis included data on numbers of outpatient retail prescriptions for individual psychotropic drugs and drug classes, along with information on costs and expenditures. The principal data source at that time was “SDI/Verispan, VONA.” The information was provided to and subsequently published on an annual basis by Drug Topics, and included listings of the top 200 prescription drugs, with separate lists for generic and brand-name drugs, and rankings according to number of prescriptions as well as dollar sales revenue. More than 5 years have elapsed, and we have updated our analysis of psychotropic drug prescribing patterns, anticipating that the landscape might have changed in significant ways. New drug entities have become available, many brand-name drugs have become generic, and some drug entities have been approved for new indications or with new dosage forms. Over the same time interval, the corporate landscape has also changed, and the extensive listings described above are no longer available. More limited listings can be obtained via sources such as Statista.com, Medscape.com, Drugs.com, and IMS Health, but none is comparable to what was available for our previous review. For the present analysis, we identified two potential sources of outpatient retail prescription data: Symphony Health Solutions Corp., and ClinCalc.com/DrugStats. Symphony covers calendar year 2014, and ranks the top 200 drugs by number of prescriptions. ClinCalc ranks the top 300 for a 12-month period from mid-2014 to mid-2015. The two sources provide similar but not identical prescription numbers for individual drugs, with Symphony estimates being on average 26% higher than those from ClinCalc. Because ClinCalc included more drugs in their ranking, we used this source for our subsequent analysis. The ClinCalc data comes from the annual Medical Expenditure Panel Survey (MEPS), a survey conducted by the Agency for Healthcare Research and Quality, a federal agency. All data is publicly available at no cost on the MEPS web site. Neither ClinCalc nor Symphony provides data on expenditures or sales. To acquire cost information, we used Data-Rx.com, which gives retail costs of all marketed brand-name and generic prescription drugs. We assumed that a typical prescription contained 100 dose units, and calculated total expenditures for that drug as the product of number of prescriptions multiplied by the cost of the typical prescription. In our earlier analysis, this calculation method yielded expenditure estimates that were close to the actual expenditures available at that time from the data base.1 With only 2 exceptions (vilazodone and lurasidone), all drugs on the list were available as generics, and most of those continued to be obtainable as the original brand names as well (Table 1). The lower generic cost was used for the expenditure estimates, and we calculated a brand/generic cost ratio when both were available. Note that we did not include stimulants, analgesics, anticonvulsants, or GABAergic drugs (gabapentin, pregabalin) in the analysis, and no information was available on drugs that did not fall into the top 300. Among drugs not represented on the list are newer agents (suvorexant, vortioxetine, paliperidone, and others), as well as older drugs (clozapine, chlordiazepoxide, triazolam, lithium, monoamine oxidase inhibitors, and others).TABLE 1: Psychotropic Drug Prescribing in the United States, 2014–2015Total psychotropic drug prescriptions for the target one-year period were just under 380 million. Of these, only 3.2 million (0.8% of the total) were accounted for by the 2 brand-name drugs; the rest were generic (Tables 1 and 2). Consistent with our previous report1 and data from other sources,2 antidepressants accounted for 58% of all prescriptions (Fig. 1). Anxiolytics, hypnotics, and antipsychotics accounted for 22%, 15%, and 5% of prescriptions, respectively. Total estimated expenditures were $29,667 million, which were not proportionately distributed between generic and brand-name drugs. Expenditures for vilazodone and lurasidone together amounted to $6,901 million – 23% of total psychotropic prescription expenditures – though these 2 drugs accounted for less than 1% of total prescriptions.TABLE 2: Summary of Psychotropic Drug Prescribing, Costs, And ExpendituresFIGURE 1: Outpatient prescriptions for antidepressants, anxiolytics, hypnotics, and antipsychotics in the United States, 2014–2015. See Tables 1 and 2 for detailed data.Antidepressant prescribing was largely comprised of serotonin reuptake inhibitors and mixed-mechanism agents (Table 1). Amitriptyline continues to be extensively used, with annual prescriptions exceeding 10 million. With the exception of vilazodone, all antidepressants on the list were available generically, with a mean cost per generic prescription of $57.13. However the arithmetic mean was biased by some high outlying values (Table 1). The brand/generic cost ratio averaged 8.1, with a wide range (1.4 to 15.8) (Tables 1 and 2). Benzodiazepine anxiolytics3 continue to be widely prescribed, accounting for more than 75 million prescriptions during the target time period (Table 1). Alprazolam prescriptions were 39% of this total. All 4 benzodiazepines on the list were generic drugs, with an average cost per prescription of $16.12. It is of interest that the overall extent of benzodiazepine prescribing in the present analysis is very close to the estimate of 80 to 90 million in the mid-1970s4,5 – numbers which elicited concern and alarm.6–8 Hypnotic prescriptions exceeded 55 million. Based on data from a number of sources,9–14 trazodone is used principally as a hypnotic though not specifically indicated for this purpose,15,16 and we categorized trazodone as such. Trazodone accounted for 46% of hypnotic prescriptions, with zolpidem17 (immediate-release and modified-release together) accounting for 38%. All hypnotics in the survey were available generically, at consistently low cost. The evident limitation of the antipsychotic prescribing data is that medication usage in non-retail settings (hospitals, clinics, and institutions) are not captured. In the setting of outpatient retail prescribing addressed in the present analysis, antipsychotics (except lurasidone) were available generically, though the generic prescriptions were substantially more expensive than those in the other drug categories. The cost of brand-name lurasidone (Latuda) was eye-catching, with each individual dose unit costing nearly $38.00 in a prescription of 100. Psychotropic medication prescribing and use are increasing yearly,2,18 reflecting the continuous increase in the population size, and the collective determination to destigmatize mental illness and use treatment options to improve quality of life. Our comment in 1975,19 which remains applicable today, noted that studies of medication prescribing numbers by themselves “ … do not provide a sole or adequate definition of treatment option, need, or efficacy.” A COMMENT ON VILAZODONE As noted above, all antidepressants, with the exception of vilazodone, were available as generics. Once drugs become generic, both direct-to-consumer advertising and clinician-office detailing taper off. At the time of FDA approval of vilazodone in 2011, FDA staff wrote that there was no evidence in the submitted data to suggest that it had “…any advantages compared to other drugs in the antidepressant class.”20 When outpatients suffering from moderate to severe depression were treated with vilazodone or placebo, about one quarter achieved clinical remission on vilazodone compared to 18% receiving placebo.21–23 Given the relatively high cost of vilazodone (Tables 1 and 2), its adoption by clinicians might bear a direct relationship to detailing and advertising. In 2017, the cost for a one-month prescription for vilazodone ranged from $231.78 and $246.99 compared to a one-month supply of sertraline ($8.70 to $27.99).24 There is no evidence to suggest that vilazodone will succeed where other antidepressants have failed.