Incentives to Reduce Metabolic Side Effects of Antipsychotics: Reply

In Reply: Drs. Knight and Young raise important questions about physicians' antipsychotic prescribing practices and the roles that financial incentives could play in changing prescribing and other patterns of care. They point to the New York State Office of Mental Health's initiative to monitor and manage antipsychotic medications and their metabolic consequences that we described in our 2010 column.

Financial incentives could be one component in changing problematic prescribing practices for people with severe mental illness. In regard to the choice of an antipsychotic, research comparing these agents has indicated that all work equivalently (except for clozapine, which works better for those who do not respond to other antipsychotics); however, side effect profiles differ (for example, metabolic and extrapyramidal affects), as do the responses of individual patients. Newly minted psychiatrists today may have little experience with older antipsychotic medications—some of which also cause metabolic abnormalities (1)—or with clozapine, which would influences what happens in their offices. It is also important to note that consumer preferences shape the choice of medication, and formulary restrictions and co-pays add further complexities to prescription decisions.

The disturbing levels of morbidity and mortality noted by Drs. Knight and Young can be attributed to factors in addition to the prescription of antipsychotic medications with metabolic side effects. Other risk factors include smoking, sedentary lifestyle, poor eating habits, substance abuse, and poor access to primary care (2). Drs. Knight and Young indicate that consumers' and providers' efforts to promote wellness are nowhere near what they should be. Our country faces the challenge of how to foster better health and nutrition and more exercise throughout the life span. Because of the liabilities of some of medications, it is particularly imperative to include people with mental illnesses in wellness efforts. Drs. Knight and Young highlight that we need integrated health, mental health, and substance abuse service systems in which financing drives good care that is consistently and accountably provided. The direction is clear, and the daunting task is to make such aligned incentives a reality.

Given the complex causes of increased mortality in this population, we need multilevel, systemic approaches to address this problem. Because a vast proportion of mental health services are paid for by Medicaid, costs for pharmacy, mental health, and general medical services are often under one payer's roof, which provides an incentive to state Medicaid agencies to pursue more integrated strategies. However, most people with serious mental illnesses can't wait for integration of care programs to reach the setting where they receive care. Although metabolic screening might ideally occur in primary care clinics with strong communications with the prescribing psychiatrist, people with severe mental illness are less likely to use primary care than the general population (3). Community mental health clinics, by virtue of serving more than 3.5 million people with severe mental illness, are effectively the “medical home” for this population (3,4). We join others in the belief that community mental health clinics should be taking a more active role in metabolic screening for this patient population (5).

Efforts such as those in New York State represent early steps toward reducing some of the morbidity and mortality in this vulnerable population. May others adopt and surpass our work. Patients, their families, and their communities deserve this.