Cost Benefits of New Schizophrenia Drugs Doubted

In statements, drugmakers AstraZeneca, which makes Seroquel, and Eli Lilly and Co., which makes Zyprexa, said patients benefit from having individualized treatment. The federal Centers for Medicare and Medicaid Services -- Medicaid picks up three-quarters of the $10 billion tab for antipsychotic drugs -- also believes that physician discretion is essential, a spokesman said.

Drug-industry critic Jerry Avorn, author of the book "Powerful Medicine: the Benefits, Risks, and Costs of Prescription Drugs" and a professor of medicine at Harvard Medical School, said this is not a case of difficult trade-offs between cost and quality.

"The cheapest drug produced an effect that was as good as the more expensive drugs," he said. "The resistance to this kind of finding comes from . . . the very legitimate worry that boneheaded cost containers will read this study and then try to get every schizophrenic on every other medication to be switched to the cheapest available product. I am a proponent of educating doctors first rather than tying our hands."

Both Insel and Robert Rosenheck, the Yale University psychiatrist who led the cost-effectiveness study, said the message was not that the half-dozen expensive new drugs should be replaced by perphenazine. Rather, they said, the message of the CATIE study is that once a range of side effects is taken into account, many older antipsychotic drugs may have risks and benefits that are similar to those of the newer drugs.

"It triples the size of the antipsychotic armamentarium available to psychiatrists," Rosenheck said. "Before CATIE, we had five to six drugs and we had tremendous pressure to not use the other 15. What CATIE has said is doctors should feel free to use whatever medicine is right for their patient, and there are 19 or 20 choices, not five or six."

Although both old and new classes of drugs have similar effectiveness in controlling symptoms such as delusions and hallucinations, the advent of the newer drugs was hailed because they seemed less likely to cause side effects involving involuntary muscle movements.

But evidence has gradually accumulated that the newer drugs do cause weight gain and serious metabolic problems. Essentially, the editorial noted, the new medications have resulted in a change in side effects, rather than eliminating them.

Rosenheck said the study means that patients paying for expensive new drugs out of pocket who wanted to switch could try perphenazine without the concern that they are getting inferior treatment. The magazine Consumer Reports recently listed perphenazine, which is sold as a generic drug, as a "best buy" among antipsychotics.

While Rosenheck and CATIE lead scientist Jeffrey Lieberman of Columbia University disagreed with the authors of the editorial on how to interpret several aspects of the study, everyone agreed that the trial provides the best window in the country to date on the treatment of schizophrenia. The editorial said the study highlighted the need for new and better treatments -- and perhaps a new and better mechanism of financial rewards to spur their development.