Therapeutic Substitution

Where We Stand

NAMI believes that all people with mental health conditions deserve access to effective medication and treatment options. NAMI supports public policies and laws that prohibit therapeutic substitution of psychiatric medications.

Why We Care

Mental health medications affect people in different ways, and individuals need to be able to access the medication that works best for them and their individual health needs. It is important that medication decisions are carefully considered with a health care provider who has both extensive knowledge of the individual and available medication options.

Sometimes, health insurers may request or require that a pharmacist substitute a person’s prescribed medication with a different medication that is expected to have the same effect. Therapeutic substitution occurs when the prescribed medication is switched to a chemically different drug. This is different from generic substitution, which means that the new medication has the same active ingredients as the prescribed medication. Therapeutic substitution is usually used to contain costs or because of drug shortages, and is often done without consulting a person’s medical provider or assessing their medical history.

For many mental health medications, therapeutic substitution can be a danger to the health of the person taking the medication, and undermines the decisions made between individuals and their health care providers. Instead, policies should include patient protections that maintain access to appropriate medications and require consent of the prescribing health care provider. Policies should specifically exclude psychiatric medications from therapeutic substitution provisions or allow the prescriber to exempt an individual’s prescription from therapeutic substitution by indicating as such on the prescription (by using terms such as “dispense as written” or “no substitutions”).

How We Talk About It

• For many people with mental illness, medication is an essential part of their treatment and can be a valuable tool in their overall well-being.
• For individuals who take medications for their mental health condition, one size does not fit all.
• Mental health medications affect people in different ways, including varying levels of effectiveness and different side effects. Because of this, it is important that a person can access the medication that works best for them.
• Where state law allows, some insurers may require pharmacists to use “therapeutic substitution” — switching a person’s prescription medication for a chemically different drug.
• For some health conditions, people can switch to a different drug without problems. However, for people with mental health conditions, therapeutic substitution can have unintended — and sometimes dangerous — consequences.
• The use of mental health medications is a decision made between an individual and their health care provider based on their symptoms, treatment history and consideration of side effects.
• While pharmacists may have some medical information about the person, they typically do not have all information necessary to make an informed decision about medication substitutions.
• When a health insurer requires therapeutic substitution without taking into account an individual’s medical history, it can pose serious risks to a person taking mental health medication.
• Therapeutic substitution is often promoted as a cost-savings strategy, but there is evidence that it can increase rates of hospitalizations and visits to the emergency room for people with major depressive disorder.
• Mental health medications should be exempted from therapeutic substitution policies because of the risks they pose to individuals. When that is not possible, providers should be able to indicate when substitutions cannot be made.
• If there is a drug shortage and an alternative medication is needed, this decision should be determined by an individual and their provider.
• Therapeutic substitution risks the safety of people with mental health conditions. State and federal policies should protect — not jeopardize — access to mental health medications.

What We’ve Done

• NAMI Policy Position on Medicare Medication Access: “Six Protected Classes”
• NAMI statement on preserving Medicare Part D access to psychiatric medications
• NAMI statement on medication choice