Friday, February 25, 2005
Depression - The Invisible Disease
Depression is a serious medical condition. In contrast to the normal emotional experiences of sadness, loss, or passing mood states, clinical depression is persistent and can interfere significantly with an individual's ability to function. There are three main types of depressive disorders: major depressive disorder, dysthymic disorder, and bipolar disorder (manic-depressive illness).
Symptoms and Types of Depression
Symptoms of depression include sad mood, loss of interest or pleasure in activities that were once enjoyed, change in appetite or weight, difficulty sleeping or oversleeping, physical slowing or agitation, energy loss, feelings of worthlessness or inappropriate guilt, difficulty thinking or concentrating, and recurrent thoughts of death or suicide. A diagnosis of major depressive disorder is made if a person has 5 or more of these symptoms and impairment in usual functioning nearly every day during the same two-week period. Major depression often begins between ages 15 to 30 but also can appear in children. Episodes typically recur.
Some people have a chronic but less severe form of depression, called dysthymic disorder, which is diagnosed when depressed mood persists for at least 2 years (1 year in children) and is accompanied by at least 2 other symptoms of depression. Many people with dysthymia develop major depressive episodes.
Episodes of depression also occur in people with bipolar disorder. In this disorder, depression alternates with mania, which is characterized by abnormally and persistently elevated mood or irritability and symptoms including overly-inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, physical agitation, and excessive risk taking. Because bipolar disorder requires different treatment than major depressive disorder or dysthymia, obtaining an accurate diagnosis is extremely important.
Facts About Depression
Depression can be devastating to family relationships, friendships, and the ability to work or go to school. Many people still believe that the emotional symptoms caused by depression are "not real," and that a person should be able to shake off the symptoms. Because of these inaccurate beliefs, people with depression either may not recognize that they have a treatable disorder or may be discouraged from seeking or staying on treatment due to feelings of shame and stigma. Too often, untreated or inadequately treated depression is associated with suicide.
Treatments
Antidepressant medications are widely used, effective treatments for depression. 6 Existing antidepressants influence the functioning of certain chemicals in the brain called neurotransmitters. The newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), tend to have fewer side effects than the older drugs, which include tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Although both generations of medications are effective in relieving depression, some people will respond to one type of drug, but not another. Other types of antidepressants are now in development.
Certain types of psychotherapy, specifically cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), have been found helpful for depression. Research indicates that mild to moderate depression often can be treated successfully with either therapy alone; however, severe depression appears more likely to respond to a combination of psychotherapy and medication. 7 More than 80 percent of people with depressive disorders improve when they receive appropriate treatment.
Research Findings
Brain imaging research is revealing that in depression, neural circuits responsible for moods, thinking, sleep, appetite, and behavior fail to function properly, and that the regulation of critical neurotransmitters is impaired.
Genetics research, including studies of twins, indicates that genes play a role in depression. Vulnerability to depression appears to result from the influence of multiple genes acting together with environmental factors.
Other research has shown that stressful life events, particularly in the form of loss such as the death of a close family member, may trigger major depression in susceptible individuals.
The hypothalamic-pituitary-adrenal (HPA) axis, the hormonal system that regulates the body's response to stress, is overactive in many people with depression. Research findings suggest that persistent overactivation of this system may lay the groundwork for depression.
Studies of brain chemistry, mechanisms of action of antidepressant medications, and the cognitive distortions and disturbed interpersonal relationships commonly associated with depression, continue to inform the development of new and better treatments.
Symptoms and Types of Depression
Symptoms of depression include sad mood, loss of interest or pleasure in activities that were once enjoyed, change in appetite or weight, difficulty sleeping or oversleeping, physical slowing or agitation, energy loss, feelings of worthlessness or inappropriate guilt, difficulty thinking or concentrating, and recurrent thoughts of death or suicide. A diagnosis of major depressive disorder is made if a person has 5 or more of these symptoms and impairment in usual functioning nearly every day during the same two-week period. Major depression often begins between ages 15 to 30 but also can appear in children. Episodes typically recur.
Some people have a chronic but less severe form of depression, called dysthymic disorder, which is diagnosed when depressed mood persists for at least 2 years (1 year in children) and is accompanied by at least 2 other symptoms of depression. Many people with dysthymia develop major depressive episodes.
Episodes of depression also occur in people with bipolar disorder. In this disorder, depression alternates with mania, which is characterized by abnormally and persistently elevated mood or irritability and symptoms including overly-inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, physical agitation, and excessive risk taking. Because bipolar disorder requires different treatment than major depressive disorder or dysthymia, obtaining an accurate diagnosis is extremely important.
Facts About Depression
- Major depression is the leading cause of disability in the U.S. and worldwide.
- Depressive disorders affect an estimated 9.5 percent of adult Americans ages 18 and over in a given year, 3 or about 18.8 million people in 1998.
- Nearly twice as many women (12 percent) as men (7 percent) are affected by a depressive disorder each year.
Depression can be devastating to family relationships, friendships, and the ability to work or go to school. Many people still believe that the emotional symptoms caused by depression are "not real," and that a person should be able to shake off the symptoms. Because of these inaccurate beliefs, people with depression either may not recognize that they have a treatable disorder or may be discouraged from seeking or staying on treatment due to feelings of shame and stigma. Too often, untreated or inadequately treated depression is associated with suicide.
Treatments
Antidepressant medications are widely used, effective treatments for depression. 6 Existing antidepressants influence the functioning of certain chemicals in the brain called neurotransmitters. The newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), tend to have fewer side effects than the older drugs, which include tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Although both generations of medications are effective in relieving depression, some people will respond to one type of drug, but not another. Other types of antidepressants are now in development.
Certain types of psychotherapy, specifically cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), have been found helpful for depression. Research indicates that mild to moderate depression often can be treated successfully with either therapy alone; however, severe depression appears more likely to respond to a combination of psychotherapy and medication. 7 More than 80 percent of people with depressive disorders improve when they receive appropriate treatment.
Research Findings
Brain imaging research is revealing that in depression, neural circuits responsible for moods, thinking, sleep, appetite, and behavior fail to function properly, and that the regulation of critical neurotransmitters is impaired.
Genetics research, including studies of twins, indicates that genes play a role in depression. Vulnerability to depression appears to result from the influence of multiple genes acting together with environmental factors.
Other research has shown that stressful life events, particularly in the form of loss such as the death of a close family member, may trigger major depression in susceptible individuals.
The hypothalamic-pituitary-adrenal (HPA) axis, the hormonal system that regulates the body's response to stress, is overactive in many people with depression. Research findings suggest that persistent overactivation of this system may lay the groundwork for depression.
Studies of brain chemistry, mechanisms of action of antidepressant medications, and the cognitive distortions and disturbed interpersonal relationships commonly associated with depression, continue to inform the development of new and better treatments.
Monday, February 21, 2005
Generic Drugs By Mail Can Be a Raw Deal
In an attempt to rein in its employees' fast-rising prescription drug costs, General Motors Corp. requires its workers to fill prescriptions for chronic conditions through the mail-order operation of Medco Health Solutions Inc. But some simple comparison shopping shows that GM, despite its formidable bargaining clout, is paying far higher prices for some drugs than ordinary individuals can get walking into retail pharmacies.
Consider GM's price for ranitidine, the generic form of the popular anti-ulcer pill Zantac. GM pays Medco $176.22 for 90 pills mailed to a worker, who pays an additional $5 co-pay, bringing the total cost to $181.22, according to Medco's Web site for GM employees. If a GM employee were to simply buy the same ranitidine prescription at a retail pharmacy, it would cost a total of $62.88 for the 90 pills. A person without insurance could buy the same medication at Wal-Mart in Secaucus, N.J., for $78.62. At Costco Co.'s online service, Costco.com, the prescription would cost only $22 -- and include 10 extra pills.
That GM pays Medco higher prices for many generic drugs than regular pharmacies charge customers without insurance illustrates the complexities, and potential pitfalls, of prescription-drug coverage. It's also a rare glimpse into how such plans work.
Pharmacy-benefit managers, such as Medco, administer the drug benefits of large employers, acting as the middlemen between the employers and the pharmacies. Such PBMs create large networks of participating pharmacies and use their size to drive down prescription-drug prices. Some, including Medco, also own their own mail-order pharmacies, and prod employers to move more of their workers' prescriptions into the mail business.
PBMs promise to realize savings for their corporate customers by keeping the overall cost of prescription medications down. But they also preserve large profit margins for themselves, as the GM prices show. The price GM pays for prescription drugs is available to any of its employees or retirees through the workers' benefits Web site. The Wall Street Journal reviewed Web page printouts provided by a pharmacist with access to the site and who is working to get GM to roll back its mandatory mail policy -- in which employers require workers to fill prescriptions through a mail program.
Some companies, like GM, say they are satisfied with the overall savings Medco is providing. But others simply aren't aware of the vast price discrepancies on generic drugs.
Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Ill., which helps employers control their drug costs through audits and contracting, says some companies are surprised when she tells them about the price differential. "It's a big deal," says Ms. Hayes. "Why should you pay more than $1 a pill for generic Prozac to the mail-order pharmacy when you could get it for 23 cents in the retail store?" she asks. [Pill Prices]
GM has used Medco to manage its drug benefit since 1994, yet the auto maker's drug costs are climbing by more than 15% a year, almost double the rate of increase of GM's overall healthcare costs.
GM's pharmacy chief, Cynthia Kirman says GM is getting a good deal from Medco, saving $80 million by using mandatory mail based on 2003's drug costs of $1.3 billion. GM declined to explain how it figures it would save $80 million. The company spent $1.5 billion on prescription drugs in 2004.
Last week GM moved to strengthen3 Medco's mandatory-mail program further by preventing its 1.1 million employees and retirees from filling any prescriptions at the Walgreen Co. drugstore chain.
GM's Ms. Kirman says its not fair to "cherry-pick" certain drugs for a price comparison, though she declined to provide a list of GM's most-used generic drugs. "Numbers on the Medco Web site may not be reflective of the actual GM prices," a GM spokeswoman said yesterday subsequently. The GM spokeswoman declined to explain why the numbers may not be reflective.
A Medco spokeswoman, too, says it is misleading to look at individual drug prices for GM and draw any conclusions about overall costs. The spokeswoman, Soraya Rodriguez-Balzac, said in an e-mail response to questions that "mail-service pricing for generics is usually a flat percentage discount for all drugs and adds value in aggregate."
Because generic drugs are so cheap to begin with, PBMs and retail pharmacies alike typically make big margins on generic drugs, which account for about half of prescriptions filled in the U.S. That's why pharmacies have a big incentive to switch prescriptions for branded drugs to their generic versions.
Aggressively switching of branded prescriptions to generics does help reduce employers' drug costs. Employers also believe they are getting better prices on branded drugs through PBMs, which is why they are willing to pay bigger markups on generic medications.
Mail-order pharmacies generally fill a three-month's supply of medication at once. Medco benefits greatly from its mail-order pricing system. When a patient fills a prescription through Medco's mail pharmacy, the full profit belongs to Medco, rather than having to split it or get very little when the transaction happens at the retail store. The Franklin Lakes, N.J., company derives more than half of its corporate profits just from selling generic drugs from its own mail order unit.
For example, 90 ranitidine pills usually cost pharmacies about $7. At retail, customers can pay $22. Medco's mail-order price to GM is $181.22. Medco can show its customers a great savings because the list price, called the average wholesale price, quotes ranitidine at about $264 for 90 pills. Medco declined to comment on specific prices on its Web site.
The dizzyingly complex system of drug pricing makes it difficult for employers to know whether they are getting the best prices. Generic drug prices in mail programs are based on average wholesale price, or AWP. AWP is considered an inflated price among those in the drug industry. For example, the average wholesale price for 90 fluoxetine pills, the generic drug for Prozac, is $240.12 but pharmacies usually pay less than $5.
Employers can't choose to use a PBM for only brand-name drugs, where they get a price break, and use another service for generic drugs. PBM services are purchased the way employers purchase a health plan -- the same health insurer covers all the different physicians and services for a worker.
Medco's generic pricing policy isn't unusual. Caremark Rx Inc., the pharmacy-benefit manager for millions of federal government employees, charges $96.05 for 90 pills of fluoxetine and $105.42 for 90 pills of ranitidine from its mail-order pharmacy. The prices are available to federal employees on Caremark's Web site.
In addition to GM, International Business Machines Corp., Southwest Airlines Co., Citigroup and numerous states and municipalities, have started mandatory-mail programs in recent years. A survey by consultant Hewitt Associates found that 22% of employers will have mandatory mail plans in place this year, with another 51% considering such programs. Copyright 2005 Dow Jones & Company, Inc.
By BARBARA MARTINEZ
Staff Reporter of THE WALL STREET JOURNAL
Consider GM's price for ranitidine, the generic form of the popular anti-ulcer pill Zantac. GM pays Medco $176.22 for 90 pills mailed to a worker, who pays an additional $5 co-pay, bringing the total cost to $181.22, according to Medco's Web site for GM employees. If a GM employee were to simply buy the same ranitidine prescription at a retail pharmacy, it would cost a total of $62.88 for the 90 pills. A person without insurance could buy the same medication at Wal-Mart in Secaucus, N.J., for $78.62. At Costco Co.'s online service, Costco.com, the prescription would cost only $22 -- and include 10 extra pills.
That GM pays Medco higher prices for many generic drugs than regular pharmacies charge customers without insurance illustrates the complexities, and potential pitfalls, of prescription-drug coverage. It's also a rare glimpse into how such plans work.
Pharmacy-benefit managers, such as Medco, administer the drug benefits of large employers, acting as the middlemen between the employers and the pharmacies. Such PBMs create large networks of participating pharmacies and use their size to drive down prescription-drug prices. Some, including Medco, also own their own mail-order pharmacies, and prod employers to move more of their workers' prescriptions into the mail business.
PBMs promise to realize savings for their corporate customers by keeping the overall cost of prescription medications down. But they also preserve large profit margins for themselves, as the GM prices show. The price GM pays for prescription drugs is available to any of its employees or retirees through the workers' benefits Web site. The Wall Street Journal reviewed Web page printouts provided by a pharmacist with access to the site and who is working to get GM to roll back its mandatory mail policy -- in which employers require workers to fill prescriptions through a mail program.
Some companies, like GM, say they are satisfied with the overall savings Medco is providing. But others simply aren't aware of the vast price discrepancies on generic drugs.
Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Ill., which helps employers control their drug costs through audits and contracting, says some companies are surprised when she tells them about the price differential. "It's a big deal," says Ms. Hayes. "Why should you pay more than $1 a pill for generic Prozac to the mail-order pharmacy when you could get it for 23 cents in the retail store?" she asks. [Pill Prices]
GM has used Medco to manage its drug benefit since 1994, yet the auto maker's drug costs are climbing by more than 15% a year, almost double the rate of increase of GM's overall healthcare costs.
GM's pharmacy chief, Cynthia Kirman says GM is getting a good deal from Medco, saving $80 million by using mandatory mail based on 2003's drug costs of $1.3 billion. GM declined to explain how it figures it would save $80 million. The company spent $1.5 billion on prescription drugs in 2004.
Last week GM moved to strengthen3 Medco's mandatory-mail program further by preventing its 1.1 million employees and retirees from filling any prescriptions at the Walgreen Co. drugstore chain.
GM's Ms. Kirman says its not fair to "cherry-pick" certain drugs for a price comparison, though she declined to provide a list of GM's most-used generic drugs. "Numbers on the Medco Web site may not be reflective of the actual GM prices," a GM spokeswoman said yesterday subsequently. The GM spokeswoman declined to explain why the numbers may not be reflective.
A Medco spokeswoman, too, says it is misleading to look at individual drug prices for GM and draw any conclusions about overall costs. The spokeswoman, Soraya Rodriguez-Balzac, said in an e-mail response to questions that "mail-service pricing for generics is usually a flat percentage discount for all drugs and adds value in aggregate."
Because generic drugs are so cheap to begin with, PBMs and retail pharmacies alike typically make big margins on generic drugs, which account for about half of prescriptions filled in the U.S. That's why pharmacies have a big incentive to switch prescriptions for branded drugs to their generic versions.
Aggressively switching of branded prescriptions to generics does help reduce employers' drug costs. Employers also believe they are getting better prices on branded drugs through PBMs, which is why they are willing to pay bigger markups on generic medications.
Mail-order pharmacies generally fill a three-month's supply of medication at once. Medco benefits greatly from its mail-order pricing system. When a patient fills a prescription through Medco's mail pharmacy, the full profit belongs to Medco, rather than having to split it or get very little when the transaction happens at the retail store. The Franklin Lakes, N.J., company derives more than half of its corporate profits just from selling generic drugs from its own mail order unit.
For example, 90 ranitidine pills usually cost pharmacies about $7. At retail, customers can pay $22. Medco's mail-order price to GM is $181.22. Medco can show its customers a great savings because the list price, called the average wholesale price, quotes ranitidine at about $264 for 90 pills. Medco declined to comment on specific prices on its Web site.
The dizzyingly complex system of drug pricing makes it difficult for employers to know whether they are getting the best prices. Generic drug prices in mail programs are based on average wholesale price, or AWP. AWP is considered an inflated price among those in the drug industry. For example, the average wholesale price for 90 fluoxetine pills, the generic drug for Prozac, is $240.12 but pharmacies usually pay less than $5.
Employers can't choose to use a PBM for only brand-name drugs, where they get a price break, and use another service for generic drugs. PBM services are purchased the way employers purchase a health plan -- the same health insurer covers all the different physicians and services for a worker.
Medco's generic pricing policy isn't unusual. Caremark Rx Inc., the pharmacy-benefit manager for millions of federal government employees, charges $96.05 for 90 pills of fluoxetine and $105.42 for 90 pills of ranitidine from its mail-order pharmacy. The prices are available to federal employees on Caremark's Web site.
In addition to GM, International Business Machines Corp., Southwest Airlines Co., Citigroup and numerous states and municipalities, have started mandatory-mail programs in recent years. A survey by consultant Hewitt Associates found that 22% of employers will have mandatory mail plans in place this year, with another 51% considering such programs. Copyright 2005 Dow Jones & Company, Inc.
By BARBARA MARTINEZ
Staff Reporter of THE WALL STREET JOURNAL
