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A recent opinion piece in Al Jazeera titled "Mass psychosis in the US" claims that antipsychotic drugs are overused in the US, mostly due to the influence of "Big Pharma" which is pushing new atypical antipsychotics.

Has America become a nation of psychotics? You would certainly think so, based on the explosion in the use of antipsychotic medications. In 2008, with over $14 billion in sales, antipsychotics became the single top-selling therapeutic class of prescription drugs in the United States, surpassing drugs used to treat high cholesterol and acid reflux.

The article states that the sales of antipsychotics have surpassed the sales of blockbusters such as statins. The article also quotes several people implying that the increased use of those drugs is caused by the pharmaceutical industry pushing to widen the criteria of mental ilnesses in order to be able to sell more drugs:

Under the tutelage of Big Pharma, we are "simply expanding the criteria for mental illness so that nearly everyone has one." Fugh-Berman agrees: In the age of aggressive drug marketing, she says, "Psychiatric diagnoses have expanded to include many perfectly normal people."

The article cites the revenue data for the drugs, but that can be misleading as the drugs are not all equally priced. It seems hard to believe that antipsychotics are more often used than statins considering the frequent reports of an obesity epidemic. Are the revenue numbers due to a vast increase in prescription of antipsychotics, or are there other factors at play like e.g. generics that push down the price of certain drugs and decrease the total revenue?

Is there evidence that antipsychotics are widely prescribed unnecessarily like the article implies?

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    There are a few different claims involved. (1) Does marketing by big pharma cause increase drug use? (2) Are antipsychotics used more frequently than statins? (3) Do antipsychotic drugs help the average person that takes them with their psychic problem? (4) Do the benefits of the drugs outweigh the side effects? - Could you be more specific about which claim you are targeting? – Christian Jul 16 '11 at 17:18
  • Not exactly antipsychotic, but related: Use of antidepressant drugs in the United States doubled between 1996 and 2005 reuters.com/article/2009/08/04/… – vartec Jul 16 '11 at 23:34
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    @Christian, I named the claims in the last part of the question. I'm interested whether the revenue numbers are misleading and whether there is an increasing amount of antipsychotics prescribed without medical need. – Mad Scientist Jul 17 '11 at 13:36
  • I suspect that school children are at increased risk of being medicated unnecessarily in the USA because schools can get $400 for each ADHD diagnosis, and I wonder if this might also be a contributing factor of overuse in general: Your child's school can receive $400 for each ADHD diagnosis (ezinearticles.com/?id=751174) – Randolf Richardson Jul 18 '11 at 5:59
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The Numbers

Sources: Top 200 Pharmaceutical Sales 2009 - U.S. Sales and Prescription Information 2009

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The Shenanigans

About a year ago, patients began trooping into the office of UCLA psychiatrist Andrew Leuchter, asking whether an antipsychotic drug called Abilify "might be right for them." Few appeared to be delusional, plagued by hallucinations or suffering fearsome mood swings. Mostly, they were depressed or anxious, and frustrated by the pace of their recovery.

Leuchter wondered what was up: Depressed patients didn't usually seek out drugs used to quell psychiatry's most disturbing symptoms.

What was up, he soon discovered, was spending on a new advertising campaign touting Abilify as an "add-on" treatment for depression. For the first time since the arrival of a new generation of antipsychotic medications -- six drugs called the "atypicals" because they work differently from the earlier generation of antipsychotic drugs -- the makers of one, Abilify, had been granted the legal right to market to a vast new population of patients beyond those with schizophrenia or bipolar disorder. - source

OK. Nothing wrong with some advertising, right? We know the rules.

Advertising and Marketing - Pharmaceutical manufacturers make substantial investments on marketing to consumers and physicians, which may influence consumer demand and physician prescribing practices. Furthermore, the most heavily advertised products tend to be newer, more expensive drugs. This results in overall increases in spending. - source

The guys at Healthcare Finance News are bullish...

The broad clinical profile of atypical antipsychotics allows them to target a spectrum of psychiatric indications, increasing access to a wider variety and larger number of patients and therefore driving sales prescriptions and revenues. Pursuing indication expansion, AstraZeneca’s Seroquel (quetiapine) and Eli Lilly’s Zyprexa (olanzapine) became the biggest selling antipsychotics in 2008 with global sales of $5.5 bn and $5.4 bn respectively. - source

2007: Fine: $515 million. Oops.

In 2007, Bristol-Myers Squibb and a subsidiary paid $515 million to settle federal and state investigations into marketing of its antipsychotic drug Abilify. - source

2009: $615 million penalty for the federal criminal charge.

[Eli Lilly & Co.]’s internal documents, which number about 10,000 pages, were unsealed as part of suits against the drugmaker by health insurers and pension plans seeking to recoup monies spent on Zyprexa. The insurance plans contend the papers indicate that Lilly promoted the antipsychotic to doctors treating elderly patients even after March 2001.

The plaintiffs cite documents including a 2002 business plan calling for expanding prescriptions in off-label use. They also point to notes from Lilly sales representatives through 2003 recording efforts to press doctors to prescribe elderly patients Zyprexa for mood symptoms, irritability and insomnia. - source

2009: Fine: $520 million.

AstraZeneca becomes the fourth pharmaceutical giant in the last three years to admit to federal charges of illegal marketing of antipsychotic drugs, a lucrative category of medications that have quickly risen to the top of United States sales charts. Aggressive sales and promotional practices have helped expand the use of powerful new antipsychotic drugs for children and the elderly. - source


Manageable side effect

In 2001, marketing executives advised salespeople not to duck questions about whether Zyprexa caused some users to gain weight, according to an internal memo.

“Acknowledge weight gain but present it as a manageable side effect,” Lilly advised its sales force, according to the documents. “With most customers, we will continue to address the diabetes concern only when it arises,” the December 2001 document said. “Get back to selling!” - source

Smoke and mirrors

The company has argued that people who were found to have diabetes after taking Seroquel already had diabetes or had existing conditions that made them at high risk of the disease.

According to company e-mail unsealed in civil lawsuits, AstraZeneca “buried” — a manager’s term — a 1997 study that showed Seroquel users gained 11 pounds a year, while publicizing a study that claimed users lost weight. Company e-mail messages also refer to doing a “great smoke-and-mirrors job” on unfavorable studies. - source

Of course nobody did anything wrong...

In its statement, Lilly said the settlement did not change its views that Zyprexa is a safe and effective treatment for mental illness.

"We wanted to reduce significant uncertainties involved in litigating such complex cases," Sidney Taurel, Lilly’s chief executive, said in the statement. - source


The Bottom Line.

"Is there evidence that antipsychotics are widely prescribed unnecessarily like the article implies?"

Yes. In fact, there is evidence that the article is right about many things.
However, it would be better served if it did not take liberties with statistics.

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    “that hardly matters” – well, I beg to differ. I think it does matter quite a bit – but unfortunately the bad use of statistics appears to be the norm in journalism (and elsewhere). – Konrad Rudolph Jul 18 '11 at 12:49
  • @Konrad I have no idea why I wrote that. Corrected. – Rusty Jul 19 '11 at 7:38
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Increasing off-label use of antipsychotic medications in the United States, 1995–2008, Pharmacoepidemiology and Drug Safety Volume 20, Issue 2, pages 177–184, February 2011

Antipsychotic use increased from 6.2 million (M) treatment visits (95% CI, 5.4–7.0) in 1995 to 16.7 M visits (15.5–18.2) in 2006, then declined to 14.3 M visits (13.0–15.6) by 2008. A shift occurred from typical agents in 1995 (84% of all antipsychotic visits) to atypical agents by 2008 (93%). As they declined, typical medications shifted toward use in schizophrenia (30% in 1995 to 48% 2008). In contrast, use of atypical agents expanded for bipolar affective disorder (10 to 34%), remained stable for depression (12 to 14%), and declined for schizophrenia (56 to 23%). Overall, antipsychotic use for indications without FDA approval increased from 4.4 M visits in 1995 to 9.0 M in 2008. The estimated cost associated with off-label use in 2008 was US$6.0 billion.

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