(May 10, 2016) "In November of last year, Olfson and colleagues reported that clozapine use for individuals with schizophrenia continues to be very low in the United States, compared to other western countries. Equally concerning, however, was their finding that there is a 7-fold variation in clozapine use by state, from South Dakota, where 15.6% of Medicaid recipients with schizophrenia receive clozapine, to Louisiana, where only 2% receive clozapine. This report was subsequently enlarged using pharmacy data by the Treatment Advocacy Center.
"Many reasons have been put forth for the overall low rate of clozapine use, including the administrative complexity of the monitoring program, the low Medicaid reimbursement system and the role of pharmaceutical companies who promote their patented antipsychotic. However, I am not aware of any study that has attempted to ascertain the reasons for the 7-fold difference in clozapine use among the states.
Not Related to Availability of Psychiatrists
"In my quest to understand the reasons for the differences, I found several factors that affect the numbers of prescriptions for clozapine. Because of its mandatory blood monitoring requirements, clozapine is usually prescribed by psychiatrists rather than by other medical 
practitioners. There is a more than 5-fold difference in the number of psychiatrists among states, which is reflected in the number of prescriptions for clozapine. For example, there are 3,545 people per psychiatrist in Massachusetts and 18,997 people per psychiatrist in Idaho.
"I compared the rank order of the states by clozapine use with the rank order by people per psychiatrists and found that the association was only slightly positive (Spearman's nonparametric; rho = 0.26) and not statistically significant. Thus, the distribution of psychiatrists in the United States explained very little of the differences in clozapine use among states.
"Next I looked at the urban-rural differences. It is easier to monitor clozapine use in urban areas, where patients can get to clinics relatively easily, than in rural areas where patients may have to travel great distances. As seen in the Table, however, many of the states with the highest use of clozapine, such as South Dakota, Vermont, North Dakota, Wyoming and Montana, are among the most rural of all the states. Urbanicity clearly is not the answer.
Use by Type of Provider
"The next question that I examined was what organization has clinical responsibility for providing psychiatric care to each state's Medicaid population. According to data from the Kaiser Family Foundation, 34 states and the District of Columbia use for-profit managed care companies to manage medical care, including behavioral health, for at least some of the state's Medicaid population. The other 16 states do not.
"As seen in the Table, the states not using for-profit are disproportionately represented at the top of the list of clozapine use. In fact, 8 of the 16 states that do not use for-profit managed care are included among the 13 states with the highest clozapine use. When the average clozapine use rate for the 34 states using for-profit managed care (4.7%) is compared with the 16 states not using for-profit managed care (6.9%), there is a strong association between lower clozapine use and for-profit managed care, although the association does not achieve statistical significance (Wilcoxon rank sum test; p = 0.08). To examine this association in greater detail would require a detailed analysis on the use of managed care for each state for 2006 to 2009, the same years as the clozapine use data....
"Since clozapine is administratively more expensive to use initially but has been proven to save money in the long run by decreasing re-hospitalization rates, are the for-profit managed care companies only interested in short-term profits? And are for-profit managed care companies associated with other indicators of inferior psychiatric care? Since for-profit managed care is spreading rapidly, these questions need answers."
E. FULLER TORREY, MD
Associate Director of Research, Stanley Medical Research Institute
Founder and member of the board, Treatment Advocacy Center
Co-chair, Psychiatric Advisory Board to the Treatment Advocacy Center
Excerpted from Psychiatric Times
References:
- Torrey, E.F. (March 2016). Why clozapine use varies by state. Psychiatric Times.
- Torrey, E.F., Knable, M.B., Quanbeck, C., Davis, J.M. (November 2015). Clozapine for treating schizophrenia: A comparison of the states. Treatment Advocacy Center.
Next week: Prevalence of Treated and Untreated Severe Mental Illness by State
Research Weekly is a summary published as a public service of the Treatment Advocacy Center and does not necessarily reflect the findings or positions of the organization or its staff. Full access to research summarized may require a fee or paid subscription to the publications.
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