OBJECTIVE: The little information available about prescribing patterns for persons with posttraumatic stress disorder comes from male combat-veteran populations treated through programs of the Department of Veterans Affairs. The objective of this study was to comprehensively evaluate prescribing patterns for persons with a diagnosis of posttraumatic stress disorder (PTSD) in a community-based nonveteran sample in which women were well represented. METHODS: Prescription claims paid in December 1999 for New Hampshire Medicaid recipients with diagnostic codes for PTSD were analyzed. Frequencies of prescriptions for categories of medication were compared between patients with PTSD (N=165) and patients with major depression alone (N=2,208) and those with major depression co-occurring with PTSD (N=171). RESULTS: The patients with PTSD were predominantly women who were receiving services at community mental health centers. Selective serotonin reuptake inhibitors were more frequently prescribed for major depression (32 percent of cases) than for PTSD (23 percent). Other novel antidepressants were more frequently prescribed for major depression co-occurring with PTSD (25 percent of cases) than for major depression alone (18 percent). Atypical antipsychotic medications were more frequently prescribed for PTSD (17 percent of cases) and for major depression co-occurring with PTSD (20 percent) than for major depression alone (9 percent). Benzodiazepines and related hypnotics, trazodone, and mood stabilizers were more frequently prescribed for major depression co-occurring with PTSD than for major depression alone. CONCLUSIONS: The findings suggest that many outpatients who have PTSD are treated aggressively with medication, particularly when PTSD co-occurs with major depression, and that there are discrepancies between actual prescribing patterns and prescribing guidelines. These findings overlap trends observed in veteran populations.

OBJECTIVE: The authors describe per-capita Medicaid and Medicare expenditures across age cohorts for individuals with schizophrenia and compare expenditures for patients with schizophrenia and those with depression, dementia, and non-psychiatric medical disorders. METHODS: Medicaid and Medicare claims were identified for dually-eligible beneficiaries ages 19+ in New Hampshire during 1999 (schizophrenia: N=1,423; depression: N=2,219; dementia: N=1,942; medical disorders alone: N=4,260). Annual per-capita weighted average expenditures were calculated for inpatient, outpatient, home-health, nursing home, pharmacy, physician, and other services. RESULTS: The greatest per-capita expenditures for individuals with schizophrenia were among older beneficiaries ($39,154 for ages 65-74 and $43,461 for ages 75+), versus younger beneficiaries ($25,633 for ages 19-44 and $31,529 for ages 45-64). Outpatient services were the highest expenditure among younger adults (ages 19-64), whereas nursing home services were the highest expenditure for ages 65+. Total expenditures for individuals with schizophrenia exceeded those for individuals with depression, dementia, or medical disorders across all age cohorts except age 45-64, where dementia expenditures were highest. Among individuals age 65-74, per-capita expenditures for schizophrenia were $11,304 higher than for depression and $28,256 higher than for medical disorders. CONCLUSION: Schizophrenia is one of the most expensive disorders across the adult lifespan, and expenditures increase across age cohorts. Effective interventions are needed that improve independent functioning in older age, in conjunction with innovative models of home- and community-based services that decrease high use of and expenditures for nursing homes.

Little is known about antipsychotic combination therapy, although this practice is becoming increasingly common in the treatment of schizophrenia. Medicaid pharmaceutical claims for a cohort of 836 New Hampshire beneficiaries with schizophrenia or schizoaffective disorder were followed from 1995 through 1999. Use of traditional and atypical antipsychotic medications, antidepressants, anxiolytic hypnotics, and mood stabilizers was tracked monthly. The number of medications, frequency of coprescription, and Medicaid pharmaceutical costs are described. The proportion of individuals with schizophrenia and schizoaffective disorder treated with atypical antipsychotics grew from 43 percent in 1995 to 70 percent in 1999. At the same time, concurrent use of two or more antipsychotic medications quadrupled, increasing from 5.7 percent to 24.3 percent. Persons with schizophrenia were also prescribed more antidepressants (increased from 18.5% in 1995 to 35.6% in 1999), anxiolytics (increased from 19.9% to 33.5%), and mood stabilizers (increased from 17.7% to 30.0%). The increase in multiple agent therapy appears to be broad-based. Data are needed on the effectiveness and cost-effectiveness of these practices to inform clinical decision making and health policy.