CAN PROZAC CUT HEALTH COSTS? IT'S NOT CREEPY--IT'S A WONDER DRUG!
By LEE SMITH

(FORTUNE Magazine) – How far should a health insurer poke into your privacy? Deep enough to determine that you're depressed and maybe ought to go on Prozac? Lovelace Health Systems, a subsidiary of Cigna in Albuquerque, is putting difficult ethical questions to the test by combing through hundreds of medical charts in search of those customers who might benefit from mood-elevating drugs. Granted, it sounds sinister, but the objectives are certainly understandable and practical--even laudable. Lovelace's aims are both to cut costs in a competitive market that will not allow the insurer to raise premiums and to make the customers healthier.

Lovelace suspects that many heavy users of medical services suffer more from mental distress than physical. Heavy users are those who have been admitted to a hospital three times in a year, have visited an emergency room three times, are taking seven or more medications, or have run up bills of at least $25,000 in a year.

Confronting someone with the suggestion that he is mentally ill is clearly a touchy assignment. With the endorsement of the patient's primary-care doctor, Lovelace mails the patient a Zung questionnaire, a familiar tool in psychology devised by the late Dr. W.W.K. Zung, a Duke University professor. The Zung consists of 20 questions, such as "I enjoy looking at, talking to, and being with attractive women/men" and "I feel that others would be better off if I were dead." Those who answer no to questions like the first and yes to questions like the second are--you guessed it--presumed to be depressed.

Those respondents who fill out the questionnaire (about 30%) and score among the seriously depressed are referred to their doctors, who generally prescribe a combination of counseling and either Prozac (made by Eli Lilly), Zoloft (Pfizer), or Praxil (SmithKline Beecham). All are members of a class of drugs known as SSRIs (for selective serotonin re-uptake inhibitors). Serotonin is a natural chemical that carries messages among brain cells and whose presence creates a sense of well-being. SSRIs prevent serotonin from being broken down too quickly. The effect is not a high, but a feeling of normality that the nondepressed experience. Nonetheless, many of the depressed decline to take part. "Some say they'll let their clergymen deal with their problems," says Dr. Jeff Mitchell, Lovelace's chief of psychiatry.

The impact of SSRIs has been dramatic. The medical expenses of one group of 2,079 patients who took part in the program were $2.1 million lower in the year after they started taking the SSRIs than in the previous year. The indirect benefits may be even greater. Chronic depression is a major cause of low productivity and absenteeism. Sara Lee has asked Lovelace to screen all 500 employees at its factory in Las Cruces, New Mexico, for depression. Lovelace will then see if those who are severely depressed are also those who are missing the most days and performing below par. Lovelace and Sara Lee haven't thought out the next step yet, but it won't be surprising if those sluggish workers are told of the wonders of SSRIs.

The drugs' potential doesn't end there. Like asthma, diabetes, and hypertension, depression is one of a cluster of troublesome chronic diseases that may be responsible for 80% of health costs. The illnesses are not inevitably expensive; all can be controlled. It's the refusal of sufferers to diet, exercise, stop smoking, or even do what seems effortless--swallow pills--that leads to medical disaster. (One in five prescriptions that doctors write is never filled.) Depression is often paired with one or more of the other chronic ailments. Lovelace believes that if Prozac can get a depressed diabetic to deal with his depression and feel better about life, the patient is more likely to stick with his diabetes regimen as well. That's just a hypothesis for now, but a reasonable one. If it proves true, Prozac and its sibling drugs could be an important remedy for rising health costs everywhere.

--Lee Smith