Overdosed!

One of the biggest potential problems with the Commission’s recommendations, however, is the unacknowledged influence of the pharmaceutical industry in the Commission’s support for the adoption of medication algorithms (decision systems) that promote use of new generations of expensive antidepressants and antipsychotic drugs. The biggest customers for these drugs are cash-strapped state Medicaid programs. 

According to a January 2003 report from the Center on Budget and Policy Priorities, “prescription drug costs [are] the fastest-rising component of Medicaid costs” and they “are rising sharply because of increases in the number of prescriptions used, increases in the prices of prescription drugs, and the tendency for prescriptions to shift from older, less-expensive drugs to newer, more-expensive ones. In the past year, the great majority of states have adopted initiatives to limit the cost of, or access to, prescription drugs to slow Medicaid spending growth.” 

The New Freedom Commission cites a Texas-based project called the Texas Medication Algorithm Project (TMAP) as an evidence-based practice that leads to better consumer outcomes. Launch- ed in 1995, while George W. Bush was still governor, TMAP was developed through an “expert consensus” process that included the University of Texas, the mental health and corrections systems of Texas, and representatives from—or with strong financial ties to—the pharmaceutical industry. TMAP was funded through a grant by the Robert Wood Johnson Foundation as well as money from ten drug companies.  

The new generation psychiatric drugs—both antidepressants and anti-psychotics—represent a growth market for drug companies. “National sales of antipsychotics reached $6.4 billion in 2002, making them the fourth highest-selling class of drugs, behind cholesterol-lowering drugs, ulcer drugs, and antidepressants, said IMS Health, a company that tracks drug sales,” the New York Times ’ Erica Goode reported in May 2003. In 2002, according to NDCHealth, another company monitoring the industry, “more than 7.4 million prescriptions were written for Zyprexa and more than 7.6 million for Risperdal.” Antidepressants and antipsychotics constitute two of the four top classes of drug sales. 

The Texas program—which tends to support the first line use of these newer, more expensive antidepressants and antipsychotic drugs —became the subject of a national debate when Allen Jones, an employee of the Pennsylvania Office of the Inspector General, turned whistle-blower and revealed that key officials with influence over the adoption of TMAP in Pennsylvania had received money and perks from drug companies involved in promoting the medication algorithm. Jones’s removal from the investigation is now under FBI examination. 

In his report, posted on the website of the Law Project for Psychiatric Rights, Jones documented that the “pharmaceutical industry has methodically compromised our political system at all levels and has systematically infiltrated the mental health delivery system of this nation. They are poised to consolidate their grip via the New Freedom Commission and the Texas Medication Algorithm Project” (www. psychrights.org). 

The influence of the pharmaceutical industry has become so controversial that the National Institutes of Health recently proposed new restrictions on its employees’ financial relations with drug companies. According to a mid-July report in Mental Health Weekly , NIH employees would be limited to no more than 400 hours of outside work with payments equal to no more than 25 percent of base pay. Much of this outside employment and consulting has been on the payroll of the pharmaceutical industry. If this is a new NIH limit, imagine the extent of prior drug company direct financial influence.  

Allen Jones not only investigated the conflict of interest of Pennsylvania officials, but also pointed out that the companies that funded the start up of the Texas project were big contributors to Bush’s reelection campaign. In addition, some members of the New Freedom Commission have served on advisory boards for these same companies, while others have direct ties to the Texas Medication Algorithm Project. 

According to a May 2004 New York Times report, drug companies are using new strategies to capture the government’s lucrative Medi- caid and Medicare markets that involve a “focus on a much smaller group of customers: state officials who oversee treatment for many people with serious mental illness. Those patients—in mental hospitals, at mental health clinics, and on Medicaid—make states among the largest buyers of antipsychotic drugs. For Big Pharma, success in the halls of Congress has required a different set of marketing tactics.” For the states, increased spending on psychiatric medications is one of the biggest drivers for the current fiscal crisis that is resulting in the denial of care to Medicaid recip- ients and the uninsured.

Psychiatric medications are essential to the recovery of many people with mental illness, but they are not without risk. The dramatic increase in the use of medications in the treatment of children has given rise to questions about safety, effectiveness, and the “off-label” use of drugs without adequate age-specific scientific research. The role that antidepressants might play in adolescent suicide has recently made headlines in Britain and the U.S. There is also mounting evidence of the serious and even lethal health effects of the new anti-psychotic medications—including diabetes, serious weight gain, and heart arrhythmias. 

While these medications may help people with mental illness live meaningful lives, the scientific verdict is not in on some of the newer drugs. What we do know is that these new psychiatric drugs consume a huge share of the public health care dollar—often at the expense of other services. Political influence and big money make scary bedfellows when questions of health are in the balance. 

During the past year a number of federal agencies have been developing policy initiatives and restructuring funding incentives to promote the Commission’s recommendations. In January, the new Congress is expected to consider related funding increases. Although mental illnesses remain four of the top ten causes of disability in the U.S., according to the World Health Organization, it is unclear whether Congress will move beyond lip service and address our national crisis in mental health. 

According to a recent Bazelon Center Mental Health Policy Report, President Bush, rather than actively supporting his Commission’s recommendations, had actually “proposed cuts in his…2004 budget to the jail diversion grants program ($7 million) and the seniors mental health program ($5 million)”—two areas of critical need according to the New Freedom Commission. 

Mental illness is not a Republican or Democratic issue. While there are specific grant initiatives that will be dealt with by Congress, no comprehensive legislative package is “being proposed at this time,” Leah Young, Director of Media Services at SAMHSA (Substance Abuse and Mental Health Services Administration), told me in a telephone interview earlier this fall. “There will be a report, a roadmap” that will be issued later this year that will discuss “where we are going from here,” she said.