The treatment of psychosis: resetting the drug cost 'thermostat'.

Cost-effective means different, sometimes competing things to different observers. In addition to well-known clinical benefits, large payors such as state governments think clozapine and similarly effective antipsychotic medications will yield immediate dollar savings. They do not consider the need to shift existing resources to community follow-up, the time required to phase out hospital units, and the backlogs of new patients. In today's financial climate, legislators and other elected officials are reluctant to invest in expensive medicines and then wait for long-term savings. We must convince those who hold the purse strings that acceptable antipsychotic drugs will be expensive for at least several years to come, until more new and generic drugs appear. We must tell them firmly that our patients, doctors, and mental health systems cannot afford to rely on older medications, even though they seem inexpensive. The drug cost "thermostat" should be reset so that payors and budget reviewers realize that safe and adequate antipsychotic medications often cost $5 to $25 a day. If new dollars are not available, existing budgets may have to be restructured. For most patients, anything else is substandard.