Atypical antipsychotics: considerations for Medicaid coverage.

In every state across America, Medicaid programs are under serious budgetary pressure. The need to contain costs has led to various forms of restriction in the coverage for drug therapy, including psychiatric pharmacotherapy. Compared with conventional antipsychotic drugs, the atypical agents have higher acquisition costs but offer greater tolerability. Thus, the atypicals are widely accepted as first-line therapy for patients with schizophrenia, and they are also now being recognized for their efficacy in treating bipolar disorder. Nevertheless, the atypicals carry their own characteristic adverse effects, of which weight gain is among the most distressing, with the potential to interfere with compliance to treatment. Treatment compliance is crucial in terms of clinical outcome as well as cost containment, as inadequate compliance is clearly associated with a higher risk of relapse requiring costly rehospitalization. Therefore, antipsychotic therapy that is individually tailored to the patient's needs and thereby improves compliance may be more cost effective than restrictive drug coverage policies based only on acquisition costs. Conversely, individualization of pharmacotherapy is not feasible if some or all of the atypical antipsychotics are excluded from coverage.