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BYLINE: Adrienne Sander, Victoria Colliver

When Amy M. left her steady job to become a freelance advertising copywriter,she had no idea the antidepressant she took to combat depression would have an unexpected side effect. She couldn't get health insurance.

"I was turned down by Blue Cross, Blue Shield and Kaiser," said the 35-year-old Oakland resident, who has been taking the antidepressant Celexa for several years. "My rejection letters from the insurance companies stated the reason for the denial: antidepressants."

With nearly 19 million Americans under a diagnosis of depression, antidepressant use is skyrocketing in the United States. The newer antidepressants are the second most commonly prescribed class of drugs in the country, according IMS Health, a firm that tracks the pharmaceutical industry.

Most Americans with health insurance are covered through their employer and have little problem getting coverage for antidepressants, but almost 10 percent of those insured have individual policies because they are self-employed, unemployed or work for a company that doesn't offer insurance. That number appears to be growing, especially in the Bay Area, where the dot-com bust has forced many jobless people to find alternative coverage.

People with individual insurance are vulnerable to rejection or higher rates due to any number of pre-existing conditions because, unlike group plans, they must answer detailed questions about their medical history to qualify.

Those with pre-existing conditions such as serious heart problems or a history of cancer may not be surprised to be rejected, but millions of Americans taking antidepressants for a variety of reasons -- from anxiety to a bout of minor depression following a divorce or even to smoking cessation -- may be shocked to have that prescription come back to haunt them.

But to insurers, the widespread dissemination of these drugs is part of the problem.

"Pharmaceutical costs are one of the most expensive costs in the system right now, especially long-term maintenance drugs," said Michael Chee, a spokesman for Blue Cross of California.

In addition, experts have questioned the safety and effectiveness of these drugs. In the same week the Food and Drug Administration held hearings this month to look into whether some antidepressants cause suicidal behavior in children and teenagers, a college student taking part in a clinical trial for a new antidepressant by Eli Lilly Co. took her life.

But many people find it difficult to function without the drugs. Due to a temporary lapse in her insurance, Amy -- who does not want to use her real name for fear that her condition would jeopardize future contract jobs -- said she stopped taking her antidepressant because of the cost. Celexa ranges from $70 to more than $80 for a month's supply from online pharmacy sites.

"The psychiatrist totally scolded me for going off medication," she said. "He said I was healthy with medication and not healthy without it." She eventually got Kaiser to accept her for $303 a month, an expense that, in part, required her to move to find cheaper rent. Amy is hardly alone. When John S. retired early from his job as a Silicon Valley engineer, he had similar problems finding insurance. He said his depression is due to a chemical imbalance and that it runs in the family.

"As soon as they heard I took Prozac, they (insurers) weren't interested," said the 58-year-old San Francisco resident, who also asked not to use his real name because he has since taken another job and is concerned about employer retribution.

"I'm a perfectly normal, healthy functioning adult in our community," he said. "But because I'm taking one type of medicine, I can't get health insurance."

Use has doubled since '98

The use of antidepressants in this country has nearly doubled since 1998, with more than $13 billion in sales in 2003, according to IMS Health, a pharmaceutical consulting company. Eli Lilly reports that its breakthrough drug Prozac, the first in a new class of antidepressants, has been consumed by more than 35 million people since it was introduced to the U.S. market in 1988 and ranks second behind Zoloft in the number of prescriptions written.

A 2002 study by Columbia University researchers found that the percentage of people with a diagnosis of depression who were treated with antidepressants in an outpatient setting increased from 37.3 percent in 1987 to 74.5 percent in 1997, based on data from national medical expenditure surveys.

But insurers are inconsistent in how they deal with the matter.

"I know there are a lot more people taking antidepressants, but I haven't seen much change in underwriting practices in 10 years," said Janet Trautwein, a director at the National Association of Health Underwriters. "(Insurance companies) still consider mental health care to be a risk and a little bit of an unknown."
I
nsurers' approaches differ

A report released in 2001 by the Kaiser Family Foundation found that insurance companies have widely disparate approaches to considering depression when evaluating policy applications.

As part of the study, the health research group created several hypothetical applicants and sent them out to get insurance.
While insurers responded consistently with most of the "applicants," there was no agreement on what to do with "Emily," a healthy 56-year-old woman who started taking a low dose of Prozac following her husband's death a year earlier. Twenty-three percent of the insurers surveyed rejected her, another 23 percent quoted her a higher rate, 12 percent offered her benefits that excluded treatment for mental disorders and 27 percent offered her both higher rates and limited benefits.

"There's not nearly the consensus among underwriters about how to respond to someone who's depressed," said Karen Pollitz, one of the study's authors and a researcher at Georgetown University's Institute for Health Care Research and Policy.
Pollitz said complete denials of coverage are often higher in California than many other states because state law prohibits the exclusion of certain pre-existing conditions.

Insurance companies say they are not discriminating against people with mental illnesses. Rather, they are struggling to provide the most affordable coverage for the largest number of people.

Unlike group plans, which are subsidized by employers, individual coverage is paid for entirely by the insurance company and the consumer. If the insurers accept too many applicants who take expensive medications, they will have to raise rates for all policy holders to pay for it.
'Recreational users' Health Net, Blue Cross and Blue Shield claim they do not reject people because they take any given medication. All say they consider the entire medical history of each applicant.

Health Net spokesman Mark Morgan said that whether a person is on antidepressants is not the sole determinant of qualification. But, for the HMO's lower-cost plans, the price of the antidepressants can be prohibitively expensive.

For example, Health Net offers five plans under $100 a month for people in their 30s in the Bay Area. The company cannot offer those rates to people taking Prozac, he said, because the medication alone costs at least $91 a month. Wellbutrin runs about $108 for a month's supply, according to a price check on drugstore.com. That means after one visit to the doctor for a check up, that member has already exceeded their premium.

"A lot of people are sort of recreational users of Prozac," Morgan said, referring to people who don't have serious mental health problems but take the drug to boost their mood. "That has a tremendous cost burden on our system."

Peter Andrade, vice president of small business and individual plans for Kaiser, said it's not Kaiser's policy to decline coverage for depression or depression managed by a drug. But, he said, Kaiser does consider the price of drugs and may decline someone who is taking an "expensive" brand drug when a generic is available and clinically proven to be just as effective.

Brokers say individuals are more likely to be quoted a higher premium than to receive a flat-out rejection for antidepressant use.
"If somebody applies for insurance and they're on antidepressants for depression and it's not major -- it's mild or for anxiety -- I'm not going to say it's an automatic decline," said Phil Dougherty, of Dougherty Health Insurance Sales in Novato, who specializes in individual policies. "But because of the cost of the medication, (the insurer) may add a higher premium."

Dougherty said that when people believe they have been denied for antidepressant use, it's more likely that they have additional health problems that have contributed to the rejection.

Chronic patients' rate lower

Ethelynne Bates, a San Rafael broker, said a person taking antidepressants for a specific situation -- say, the death of a spouse -- would be considered more attractive than an applicant diagnosed with chronic depression.

However, when The Chronicle called a Health Net consumer line to inquire about coverage, one of the first questions the representative asked was whether the caller was taking any medications. When she mentioned taking Wellbutrin, the Health Net customer service rep responded, "Oh, I'm sorry. You don't qualify."

Antidepressants are often criticized for being prescribed too widely, for being ineffective or for causing intolerable side effects in some patients.
A 2002 study that raised questions about the possible overuse of antidepressants found that most people being treated for depression would not meet the relatively narrow entry requirements of clinical trials to study those drugs.

Antidepressants are prescribed for a range of conditions beyond the most common forms of depression such as postpartum depression, panic disorders, social anxiety, sleep apnea and smoking addiction.

Left untreated, mental illness has serious consequences: disability, unemployment, substance abuse, homelessness, inappropriate incarceration and suicide, according to the National Mental Alliance. Lost productivity, lost earnings and related expenses cost the U.S. $148 billion a year, according to a 1999 report from the National Institute of Mental Health.

Social costs of depression

Taxpayers absorb the expense, too, said Renee Binder, president of the California Psychiatric Association.

"Untreated people develop stress-related symptoms such as headaches, high blood pressure or stomach problems. The worst part is people without insurance will go to S.F. General -- which is very expensive medical care," she said, referring to the county hospital, which is used as a safety net by the uninsured.

Californians do have an option, albeit often an expensive one, through a state program called the Major Risk Medical Insurance Program.

People who can't find adequate coverage are guaranteed coverage if they can show they've been rejected for insurance and meet some other requirements, such as they cannot be eligible for coverage through a former employer.

Premiums for the plans, which are offered by private insurers, vary widely, depending on the region, plan and age of the applicant. In Contra Costa County, for example, a person between 50 and 54 years old can pay from $306 a month for a health maintenance organization to $796 a month for preferred provider coverage. So in some cases, even a premium rate that has been bumped up due to antidepressant use may be lower than the state plan.

Binder said uninsured patients ask whether they should lie about their mental health problems on their applications. She discourages it because they could lose coverage and be required to pay back expenses for treatment they received. 
Yet she sympathizes with their plight: "It's discrimination against people with mental illness."