Rank	Brand Name	Generic Name	# of U.S. Prescriptions	Use
10	Valium	Diazepam	14,009,000	Anxiety, Panic disorder
Benzodiazapene – Positive allosteric modulation of GabaA Receptors – (Facilitates GabaA inhibition in use dependent manner)
9	Effexor XR	Venlafaxine	14,992,000	Depression,Anxiety, Panic disorder – “Off-label” for diabetic neuropathy and migrane
Serotonin-norepinephrine reuptake inhibitor (SNRI) – increases serotonine and norepinephrine
8	Seroquel	Quetiapine	15,814,000	Schizophrenia, Bipolar disorder, “add-on” for Depression
“Atypical antipsychotic” – Blocks dopamine, serotonin, adrenergic and histamine receptors
7	Cymbalta	Duloxetine	16,626,000	Depression,Anxiety, fibromyalgia, diabetic neuropathy
Serotonin-norepinephrine reuptake inhibitor (SNRI) – increases serotonine and norepinephrine in a use dependent manner
6	Desyrel	Trazodone	18,873,000	Depression, Bipolar Depression (sometimes), Anxiety
Predominantly a 5-HT2A receptor antagonist, also 5-HT1A partial agonist and Selective Serotonin Reuptake inhibitor (SSRI)
5	Prozac	Fluoxetine	19,499,000	Depression, Anxiety, OCD, Bulemia, PMDD
Selective Serotonin Reuptake inhibitor (SSRI), 5-HT2C receptor antagonist, σ1 Receptor agonist
4	Zoloft	Sertraline	19,500,000	Depression,Anxiety, OCD,PTSD, PMDD
Selective Serotonin Reuptake inhibitor (SSRI) – Weak σ1 receptor agonist and α1-adrenoreceptor antagonist
3	Ativan	Lorazepam	25,868,000	Anxiety, panic disorder
Benzodiazapene – Positive allosteric modulation of GabaA Receptors – (Facilitates GabaA inhibition in use dependent manner)
2	Lexapro	Escitalopram	27,698,000	Depression,Anxiety
Selective Serotonin Reuptake inhibitor (SSRI)
1	Xanax	Alprazolam	44,029,000	Anxiety
Benzodiazapene – Positive allosteric modulation of GabaA Receptors – (Facilitates GabaA inhibition in use dependent manner)

It’s a little crazy, pun totally intended, how much we’re prescribing SSRIs, when some meta analyses say they aren’t much better than placebo. Placebo effects are probably doing something very physiological in this case, by relieving anxiety. I would say that sugar pills would be a lot cheaper and save us money, but I don’t think we need more sugar either. Maybe, we should go Germany’s route and prescribe St. John’s Wort for mild depression?

• 10. Hydrochlorothiazide (various brand names) lowers blood pressure — 47.8 million
• 9. Generic Glucophage (metformin) diabetes drug — 48.3 million
• 8. Amoxicillin (various brand names) antibiotic — 52.3 million
• 7. Azithromycin (brand names include Z-Pak and Zithromax), antibiotic — 52.6 million
• 6. Generic Prilosec (omeprazole), antacid drug — 53.4 million (does not include over-the-counter sales)
• 5. Generic Norvasc (amlodipine besylate), angina/blood pressure drug — 57.2 million
• 4. Generic Synthroid (levothyroxine sodium), synthetic thyroid hormone — 70.5 million
• 3. Lisinopril (brand names include Prinivil and Zestril), blood pressure drug — 87.4 million
• 2. Generic Zocor (simvastatin), cholesterol-lowering statin drug — 94.1 million
• 1. Hydrocodone (combined with acetaminophen), opiate/painkiller — 131.2 million

This list doesn’t contain any psychiatric drugs–Xanax just barely misses the cut–but the #1 drug, hydrocodone, is psychoactive. However, while our #1 psychiatric drug did not make it into the top 10 most prescribed, our #8 drug, the atypical antipsychotic Seroquel clocks in at #6 on the drugs we spend the most money on (shown bellow).

Also of note, is the #1 most prescribed drug for teenagers. Can you guess what it is? Methylphenidate, Ritalin, the ADHD medicine. I’m most surprised it’s not adderall at this point.

According to ABC news: “The United States makes up only 4.6 percent of the world’s population, but consumes 80 percent of its opioids — and 99 percent of the world’s hydrocodone, the opiate that is in Vicodin.” Our use of hydrocodone and other opiate painkillers has many issues: such as diversion and abuse and use as a bandage in chronic pain or injury instead of treating underlying issues (where it may even make pain worse in the long term). Another startling new trend, is the spike in newborns born dependent on opiates:

The best sellers are often generic drugs, so it is also interesting to see where “big pharma” is making the most money:

Top 10 drug we spend the most money on in the United States overall (according to IMS Institute for Healthcare Informatics in 2011)

• 10. Epogen, injectable anemia drug — $3.3 billion
• 9. Actos, diabetes drug — $3.5 billion
• 8. Crestor, cholesterol-lowering statin drug — $3.8 billion
• 7. Singulair, oral asthma drug — $4.1 billion
• 6. Seroquel, antipsychotic drug — $4.4 billion
• 5. Abilify, antipsychotic drug — $4.6 billion
• 4. Advair Diskus, asthma inhaler — $4.7 billion
• 3. Plavix, blood thinner — $6.1 billion
• 2. Nexium, antacid drug — $6.3 billion
• 1. Lipitor, cholesterol-lowering statin drug — $7.2 billion

Note the atypical antipsychotics Seroquel and Abilities. One meta-analysis of antipsychotics, showed they have questionable benefit over the now-generic typical antipsychotics, and were not a cost-effective answer. The studies analyzed all suffer from the same difficulties that genetics studies of schizophrenia do, because patients are so heterogeneous and diagnoses are somewhat subjective. Atypical prescriptions are probably too high, due to advertising and “newer is better” kind of thinking, but because the disorders are heterogeneous, I’m glad that we have more drugs to choose from and try out with individual patients.

Also, I’m also shocked that antacid drugs can make that much money, but I guess it’s in a different ballpark than Tums.

References / Further Reading
Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. New England Journal of Medicine, 358(3), 252-260. Massachusetts Medical Society. doi:10.1056/NEJMsa065779

Hanrahan, P., Luchins, D. J., Fabian, R., & Tolley, G. (2006). Cost-effectiveness of atypical antipsychotic medications versus conventional medication. Expert Opinion on Pharmacotherapy, 7(13), 1749-1758. Expert Opinion. doi:10.1517/14656566.7.13.1749