Viagra: Prozac revisited?

By Russ Newman, PhD, JD
APA Executive Director for Practice

A recent headline in the April 22 Washington Post read: 'Doctor Restraint Could Decide Who Will Buy Impotence Pill.' The accompanying article described Viagra, Pfizer?s new drug developed to combat male impotence, and addressed the question of who is going to pay for it. If the drug is used to treat clinical impotence, the article concludes that insurers are likely to pay. In fact, it may even save money as a more cost-effective alternative than existing treatments for impotence. If, however, Viagra becomes widely used for normal men looking to enhance sexual performance, third-party payers will be considerably more reluctant to cover it for fear of its effect on health-care costs. Relying on physician restraint to limit drug use and, thereby, shape reimbursement policy does not bode well if history is to be our guide.

Take Prozac as an example. Sales of the drug in 1993 reached a record, at the time, of $1.2 billion. In 1997, sales of the increasingly popular drug hit $2.56 billion. The sales of Prozac, Zoloft and Paxil combined are $5.5 billion. Far from showing restraint in prescribing Prozac, physicians have extended its use beyond diagnosable clinical depression to individuals who are unhappy or dissatisfied with themselves. These are individuals who may experience themselves as not outgoing enough, not energetic enough, not mentally quick enough or not productive enough. In effect, the drug has been used to 'treat' or eliminate perceived inadequacies or personality deficiencies. It has been prescribed for both adults and children , although not specifically tested for the latter group. 'Restraint' would probably not be the first word to come to mind to describe prescribing patterns for Prozac.

If you think Prozac is just an anomaly, think again. A study of psychotropic prescribing patterns reported in the February 1998 Journal of the American Medical Association is enlightening. When prescribing patterns in 1985 are compared with a comparable period in 1993 and 1994, psychotropic medication use in outpatient medical practice increased dramatically. The number of visits during which a psychotropic medication was prescribed increased from 32.73 million to 45.64 million. Psychotropic medication visits of children and adolescents increased from 1.1 million to 3.73 million. Antidepressant visits surpassed antianxiety drug visits, with an increase from 10.99 million drug visits for depression to 20.43 million visits. Stimulant drug visits increased from 0.57 million to 2.86 million. Psychotropic medication visits to psychiatrists almost doubled, increasing from 7.7 million to 15.09 million. Not much restraint apparent here.

Although only on the market for a few weeks at the time of this writing, it is reported that doctors are writing as many as 40,000 Viagra prescriptions a day. Consider, too, that the drug has not been out long enough for anyone to require a prescription renewal. This is three times higher than the number of new prescriptions for Prozac, although the data show 70,000 Prozac prescriptions, both new and renewed. It is unknown yet as to what percentage of prescriptions are for men seeking increased sexual performance in contrast to those who are being treated for impotence. The only restraint on Viagra evident so far is, by some media accounts, the inappropriate practice by some insurers of reimbursing the medication use only when the impotence problem is deemed to be organically caused but not reimbursing psychologically determined impotence.

To the extent that the use of Viagra, as with Prozac, goes far beyond those with an actual diagnosable disorder, it can hardly be attributed to just the lack of individual physician restraint. Rather, it is the convergence of a 'quick fix' society with the traditional medical model approach to prescribing, which works to isolate the diseased organ and then to 'cut it out' or 'medicate it away.' Whether the medical model or quick fix society came first is perhaps a 'chicken and egg' dilemma, although I have my suspicions. Add to these factors the pressure by managed care to treat with medication and the escalating drug numbers are perhaps not so surprising.

To their credit, some Pfizer researchers are concerned that Viagra not be used without accompanying psychological therapy. It is possible that use of the new drug could contribute to the public?s increasing sophistication of the interplay between physical and psychological factors. Unfortunately, it is also possible that the promise of an easy drug solution for sexual dysfunction will be yet another addition to this country?s intractable chemical dependency problem.

Psychologists have?or at least should have?much to contribute to ensure an integrated psychological and physical approach. This is true even assuming psychologists are ultimately able to prescribe. In fact, psychologists trained to prescribe through a psychological model of understanding disorder and treatment (rather than a medical model) may be even better able to integrate the physical and psychological. That is a goal worth pursuing.