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By Leila Abboud, the Wall Street Journal The Food and Drug
Administration's warning on antidepressants this week is likely to add
fuel to a separate debate about an even more powerful class of
mental-health drugs. A growing number of
general physicians are now prescribing potent drugs called atypical
antipsychotics. The drugs are approved for patients with schizophrenia and
bipolar disorder. General physicians are also prescribing the drugs for
people with persistent depression, elderly patients with dementia, and
children with severe behavioral problems. In the past, such drugs
were largely prescribed by psychiatrists. Some psychiatrists are critical
of the emerging role of nonspecialists, arguing that general-practice
physicians don't have enough specific training to dispense drugs to people
with serious mental illness. The shift comes amid
increased concern about the potential side effects of other drugs used to
treat more common types of mental problems. On Monday, the FDA urged
doctors to closely monitor children and adults taking antidepressants
because they may be at risk of committing suicide. That recommendation
could prompt doctors to become more cautious about how and when they
prescribe antidepressants. Some psychiatrists worry that antidepressants
are sometimes prescribed in cases of mild mood swings rather than
full-blown depression. Today, doctors who aren't psychiatrists write 75%
of all prescriptions for antidepressants. The FDA hasn't taken a
position on primary-care doctors prescribing antipsychotics, nor is there
any evidence that the class of drugs is linked to suicide risk. But many
of the drugs have serious side effects, which require careful monitoring.
These include weight gain, an adverse impact on blood fats called lipids,
and diabetes. Last year, general
physicians wrote some 30% of the country's prescriptions for
antipsychotics -- or 488,245 prescriptions -- according to research
company NDCHealth. That compares with 16.6% of prescriptions just three
years ago. While some of these doctors are likely writing prescriptions
only for drug refills, others are diagnosing mental illnesses and putting
people on antipsychotics for the first time. Over the past three years,
prescriptions from general practitioners have grown nearly twice as fast
as those written by psychiatrists, based on a calculation using the
NDCHealth data. RISK
FACTOR Side effects of some of
the new antipsychotic drugs DRUG MAKER COMMENT
Zyprexa Eli Lilly: The
most costly drug of the group. Side effects include weight gain and
adverse impact on blood fats, including cholesterol.
Risperdal Johnson &
Johnson: When taken at high
doses, Risperdal can lead to jerky movements.
Seroquel AstraZeneca:
Some people taking Seroquel can experience sleepiness, dizziness.
Geodon Pfizer:
Not widely used partly because the FDA required warning labels
about the drug's possible triggering of irregular heart rhythms.
Abilify Bristol-Myers
Squibb: Physicians are
increasingly prescribing Abilify because they believe it doesn't cause as
much weight gain as some other antipsychotic drugs.
Antipsychotics are more
powerful than antidepressants, and are generally used to treat more
serious and difficult-to-diagnose illnesses. The newer antipsychotics have
eliminated some of the particularly unpleasant side effects associated
with previous versions of the drugs, including jerky limb movement. But
side effects remain. Last fall, for example, the FDA asked drug makers to
start including warning labels on the medicines about diabetes risk. Some psychiatrists say the
drug companies that make antipsychotics have too much sway over the
prescribing habits of the primary-care physicians. The drug industry's
"sales forces are driving the use of antipsychotics in the
primary-care market," says Steven Dubovsky, vice chairman of the
department of psychiatry at the Primary-care doctors say
they're confident they can prescribe antipsychotics because the drugs have
milder side effects than previous versions. They also say they're
providing valuable treatment to seriously ill patients who would go
untreated otherwise, either because of restrictions in their health
insurance or poor access to psychiatrists. What has psychiatrists
most concerned is primary-care doctors' increasing tendency to diagnose
and treat people with bipolar disorder. That condition, marked by
alternating periods of depression and mania or milder excitement, is
particularly hard to diagnose because it comes in a variety of forms. And
the stakes are high: If inadequately treated, bipolar sufferers can end up
behaving even more erratically. It then takes more intense therapy or drug
treatment to pull them back out of that hole. Bipolar patients -- more
than 2.3 million Americans suffer from the condition -- also have high
rates of suicide and substance abuse. Primary-care doctors, who
outnumber psychiatrists by more than 7 to 1, played a big role in turning
antidepressants like Prozac into top sellers in the 1990s. When the new
antipsychotics emerged in mid-1990s, they started prescribing them as
well. "We used to refer these patients, but now we can treat them
with confidence they'll get better," says Michael Fleming, who runs a
family practice in Primary-care doctors are
prescribing the antipsychotics for a range of mental illnesses, including
"off-label" uses such as severe depression and dementia. While
not officially approved by the FDA, off-label application is legal and
common in the drug business. Sue G. Decotiis, an
internist with a large practice in Dr. Decotiis put the woman
on Symbyax, Lilly's new combination antipsychotic and antidepressant. A
month later, the woman was doing much better, Dr. Decotiis says.
"More primary-care doctors need to realize we can do this," she
says. "I think it's easy for us to do." Dr. Decotiis learned how
to use the drugs to treat bipolar disorder from continuing-education
courses funded by the drug companies. Such programs are common and
permitted by federal regulators. Two companies in
particular, Eli Lilly and J&J, have been particularly active in
courting primary-care doctors with the new drugs. Karla Birkholz, who runs
a four-doctor family practice in J&J says its sales
force only calls on the some one-third of primary-care doctors who already
prescribe atypical antipsychotics "to provide them with important
information about Risperdal." Lilly says its salespeople
visit general physicians because they are the first line of defense in
diagnosing and treating bipolar disorder. The companies also use
continuing-education courses to encourage general physicians to prescribe
antipsychotics. J&J sponsored the publication of a journal titled
"Using Atypical Anti-psychotics in Primary Care," which was sent
to 38,000 primary-care doctors. Lilly, meanwhile, funded a
continuing-education program on bipolar disorder for primary-care doctors
that was held in 29 cities last year. Psychiatrists say there are some cases in which general doctors can safely treat patients with antipsychotics. They include patients who are getting refills for prescriptions that were started by a psychiatrist, who have responded well to initial drug or therapy treatment, or whose doctors have invested a significant amount of time learning about mental health. Copyright © 2004
Global Action on Aging |
