While quality of care was a principal focus of the study, the cost of care was clearly the driving force. "The key question was whether the additional acquisition costs of SGAs over FGAs would be offset by improvements in health- related quality of life or savings in the use of other health and social care services in people with schizophrenia for whom a change in drug treatment was being considered for clinical reasons, most commonly suboptimal efficacy or adverse effects," the researchers wrote.
In their findings, however, they note that although the mean costs for patients in the FGA arm of the study were lower, the "major cost in both groups was psychiatric hospital inpatient admissions: 93.2% of total costs in the FGA arm and 81.5% in the SGA arm. Antipsychotic drug costs accounted for a small proportion of total costs (2.1% in the FGA arm and 3.8% in the SGA arm).
"This calls into question how valuable it is to think of these drugs as a class as opposed to trying to think about the right treatment for each individual," Baker noted. "Some people may take a headline, just choose only cost, but [this applies] only the farther away you are from patients and clinical realities. This signals how much you have to individualize the choices."
Lehman also worries that policy makers will use cost considerations as a way of restricting treatment options. "When we go for treatment, we don't want our choices to be constrained by costs. It would be a shame for someone not to have access to a treatment that might be better for them because of a policy decision only to have the cheaper drugs or to have to fail with a cheaper drug first. That's true for other medical conditions, as well. We are balancing a range of choices with cost.
"Instead we should look at prescribing practices that tend to drive costs up more, such as inappropriate prescribing for other indications. This is not always done by mental health practitioners but by family physicians and others who are not as familiar with the literature. We see people using multiple drugs in the same class. Why do you need to take 3 antipsychotics?
"There are lots of ways of reducing costs without restricting the nature of drugs available. That's just a blunt instrument, although policy often uses blunt instruments."