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Schizophrenia Bulletin Advance Access published online on July 18, 2007
Schizophrenia Bulletin, doi:10.1093/schbul/sbm089
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Published by Oxford University Press 2007.

Rethinking Antipsychotic Formulary Policy

RA Rosenheck1,2,3, DL Leslie2,3, Susan Busch2, Ethan S. Rofman4,5 and Michael Sernyak2,3
2 Yale Medical School, New Haven, CT
3 Northeast Program Evaluation Center (182), Veterans Affairs Connecticut Health Care System, 950 Campbell Ave, West Haven, CT 06516
4 Veterans Affairs New England Health Care System, Bedford, MA
5 Boston University Medical School, Boston, MA

1 To whom correspondence should be addressed; tel: 203-937-3850, fax: 203-937-3433, e-mail: Robert.Rosenheck{at}Yale.Edu.

In this commentary, we review recent research suggesting that (a) second-generation antipsychotics (SGAs) may be no more effective than first-generation antipsychotics (FGAs), (b) the reduced risk of EPS and tardive dyskinesia with SGAs is more weakly supported by the research literature than has been appreciated, and (c) benefits may be offset by greater metabolic risks of some SGAs and their substantially greater cost. Bearing in mind, as well, that risperidone, currently the least expensive SGA, will soon be available as an even less expensive generic drug, we propose a new algorithm for maintenance antipsychotic therapy. We further outline a cautious implementation procedure that relies on standardized documentation and feedback, without a restrictive formulary that would limit physician choice. The algorithm outlined here and the process for its implementation are intended as a stimulus for discussion of potential policy responses, not as a finalized proposition.

Keywords: schizophrenia / antipsychotic medication / public policy


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