What’s In? What’s Out? The Popularity Contest in Psychiatric Drug Use

“Popularity is the easiest thing in the world to gain and it is the hardest thing to hold.” 

That’s what Will Rogers famously thought–but he had obviously never met Xanax.

Sometimes looking at the trajectories of various medications for mental illness seems like tracking who’s in and who’s out in the popular crowd.

And one thing’s for certain: these medications, called psychotropics, as a group, are the popular crowd.

According to “Better but Not Best” in the 2009 issue of Health Affairs,  by Sherry Glied and Richard Frank, 73% more adults and 50% more children were using drugs to treat mental illness  in 2009 than in 1996, and, among adults 65+, psychiatric medication use doubled between 1996 and 2006.

The Wall Street Journal noted in November, 2011, that use of psychiatric medications in the U.S. among adults increased 22% from 2001-2010.

That’s going some, because in the ‘good old days,’ there was a fair amount of free-dealing with these drugs, particularly with the anti-anxiety medications.

Remember Valium? In the 1970s, pharmacists were filling nearly 100 million scripts for it a year.

Enough of a rage to have a song dedicated to the ‘mother’s little helper’ by the Rolling Stones, the pill was actually pulled off the market in the UK by its makers, Roche, this past year, although it had long lost patent, and its generic continued. Known now as diazepam it’s been knocked out of the ballpark by newer drugs.

With Ativan and Xanax all the trend nowadays, there are very few people on the generic Valium.

It’s just like we learned in junior high–popularity comes and goes.

So what are the ‘meds to be on,’ if there’s such a thing, now?

Actually, in the past 7 or 8 years the drugs at the top of the charts have remained remarkably consistent.

In 2005, according to PsychCentral, the top 5 prescribed psychiatric medications in the U.S. were:

  1. Xanax (anxiety): 34,230,000 prescriptions
  2. Zoloft (depression): 26,976,000
  3. Lexapro (depression and anxiety): 24,976,000
  4. Prozac (depression): 21,403,000
  5. Ativan (anxiety and panic disorder): 19,002,000

During the time period from 1996-2005, ending here, antidepressant use almost doubled in the U.S, according to WebMD. So the numbers for drugs like Zoloft, Lexapro and Prozac were astonishingly high by the time PsychCentral did its count–higher than most people had imagined they’d ever be.

But sometimes, of course, popularity just breeds popularity.

So there’s always room for hope if you’re a pharmaceutical maker, and, in fact, the numbers didn’t decrease at all; rather antidepressant use continued to increase throughout the rest of the next decade.
There were some changes in the specifics of this ‘Top Five” list by PsychCentral’s 2011 count–but in essence most of those changes were fairly superficial (although it’s notable that the number of scripts increased for every drug).

By 2011 the top 5 were (all generics, by now):

  1. Xanax, taking it away again, this time with 47,792,000 prescriptions
  2. Celexa (coming from way behind and moving up an exciting 15 slots to grab the number 2 position–for depression): 37,728,000
  3. Zoloft (dropping from silver to bronze, but still with a significant increase): 37,208,000
  4. Ativan (moving up in the world): 27,172,000
  5. Prozac (demoted to rounding out the top 5, the number of scripts for it, too, increased notably): 24,507,000

[There’s an infographic that depicts this information, in case your eyes have glossed over. I had to work hard to restrain myself from using it, fan that I am of the visual, since it just repeats exactly what I’ve said, and thus didn’t seem to add much to the conversation. I couldn’t deprive you a look, though.]

The excitement of this race isn’t captured here, but Wellbutrin (yes, the drug for which GlaxoSmithKline is paying a pretty penny to apologize for its, mmm, ‘dishonest’ marketing techniques) rose from #22 to the 13th spot. It was great for betting folks.

You will notice that Xanax is queen bee of popularity, the Mark Spitz of psychiatric medications.

It does have one simple, perhaps unfair, advantage. Used to treat anxiety, Xanax is lucky to be around in an “Age of Anxiety.” While the mood disorders–depression and bipolar disorder–get a lot of play time in the public’s attention, anxiety disorders are actually much more common.

According to the  National Institute of Mental Health, currently mood disorders affect 9.5% of the population, while  18% of adults in the US suffer from anxiety. It’s not only the most common psychiatric complaint–it wipes the floor with its competition.

Hence Xanax–and Ativan, too–seem poised to stay in the popular crowd for years to come.

But it’s important to realize that each and every one of these drugs now has a generic, regularly and widely used. So if popularity is measured not by number of prescriptions but by money earned, these preening top 5 meds lose their prom-king-and-queen status. It is taken up by new kids on the block, relatively speaking.

As of 2010, several of the ‘second-generation’ antipsychotics, or ‘atypicals,’ had not yet gone off patent, and thus, in terms of sheer profit, they were the top-selling class of pharmaceuticals in America, with annual revenue, according to the New York Times, of  about $14.6 billion, thereby “surpassing sales of even blockbusters like heart-protective statins.”

There has been an explosion in the number of people who take them–and seemingly continues to be.

According to Business Insider, spending on antipsychotic drugs grew by $1.4 billion in 2010 — over 4 times  faster than in 2009.

Given costs, and the fact that a number didn’t lose (or still haven’t lost) patent until late in the game, WebMD asserted that, in the ‘top-10 best-selling drugs” of 2010, there were two  atypicals: Abilify, in fifth place with  $4.6 billion in sales, and Seroquel right behind it, with $4.4 billion in sales. That put them behind only blockbuster drugs Lipitor, Nexium, Plavix and Advair in the race to the bank.

By 2011, Seroquel  was up to $6 billion in revenue, with, 14.1 million prescriptions. In fact, more scripts were actually written for Seroquel than any other antipsychotic in that year. Only due to pricing did Abilify pull ahead, with $5.3 billion in sales.  Actually, if we’re to be honest about who won the popularity contest, Abilify wasn’t even the second most prescribed antipsychotic.

That honor went to Risperdal, with 12.2 million scripts. (Yes, Abilify finally comes in third.)

The antipsychotic playing field has been rife with in-groups and out-groups and sudden changes in who belongs where as trendiness has waxed and waned, given FDA approval, FDA condemnation–and new kids on the block.

In the ‘old days of antipsychotics, Thorazine came around first, in the 40s. A major tranquilizer (known as a ‘neuroleptic’), over the next 10 years 50 million patients were put on it.

New creatures, atypicals, like Risperdal and Zyprexa in the late 90s, looked like salvation from the exceedingly unpleasant adverse side effects of Thorazine and other first generation antipsychotics that came after (Haldol, anyone?).

These atypicals as a whole have clearly become the popular crowd.

From 1997-2007, the total number of prescription purchases of antipsychotics increased from 17.4 million in 1997 to 32.4 million.

But their path has been tempestuous as well.

For example, Zyprexa, the second atypical antipsychotic to win approval for treating  schizophrenia in the late 90s. By 2002 doctors were writing 7.4 millinos prescriptions a year, and by 2003 the number had jumped to 11.092 million. However, a 2005 lawsuit against 2005 Zyprexa’s makers, Eli Lilly  from people who claimed to have developed diabetes and other disorders from the drug moved it out of the running.

In 2008 there were 4 million scripts written. (In 2011 Lilly laid down its fight, and its patent expired. Zyprexa is now olanzapine when she’s at home.)

There’s always someone ready to take the place at the top. Dubbed by some a ‘third-generation neuroleptic,’ Abilify, approved in 2002, works differently than Risperdal, Zyprexa, and Seroquel, and is again supposed to have fewer of the adverse side effects that these new drugs had, in turn.

That’s how you get away with charging the big bucks–and keep your place in the top 10 earners.

NewsNet5 shopped around for the cheapest prices for the most expensive pills, finding the best bargains on a month’s prescription. They located a local drugstore named Marc’s which had the lowest out-of-pocket price for Abilify–at a more than $883.99.

And how can I leave the psychotropic popularity topic without sharing the Wall Street Journal’s statistic, that use of ADHD meds like Concerta and Vyvanse tripled from 2001-2010 in the age group 20-44, and doubled in that same time among women aged (who would have guessed?) 45-65?

Yet if Will Rogers is right, and Zyprexa’s example backs him up, every winner of today’s popularity poll is in peril of being tomorrow’s has-been when newer and better medications come out–or when the lawsuits hit. It’s rough being the head of the pack.

Although billions of dollars in sales may ease the discomfort, even if you don’t get elected class president.

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