To the Editor: Medicaid does not reimburse patients for light therapy. Dr. Wirz-Justice (1) has commented, "Light is now recommended as the treatment of choice for seasonal affective disorder. However, in spite of international recognition, only in Switzerland has the additional economic argument that light is cheaper than drugs attained government endorsement and mandatory reimbursement by medical insurance." The following case report strikingly illustrates the shortsightedness of that policy.
Ms. A, a 40-year-old Guatemalan woman living in a family shelter with four school-age children, never experienced clinical depression before moving to New York 15 years ago. Since then, she regularly experienced winter depression accompanied by hyperphagia, hypersomnia, and cravings for sweets. These bouts of depression led to her losing a nurse’s aide job and being abandoned by her husband. Treatment with venlafaxine, 375 mg/day, and later fluoxetine, 40 mg/day, provided minimal benefit in winter, but there was dramatic improvement in spring and summer. When Ms. A was initially evaluated, she was depressed and ready to drop out of a medical technician training program. We loaned her a 10,000-lux light box, which she used 30 minutes each morning. Within 2 weeks, she improved markedly. Subsequently, she finished her training and began working as a medical technician and living independently.
This case illustrates three major points:
1. Although patients with seasonal affective disorder are rarely ill enough to require hospitalization, their illness can precipitate catastrophic life events. In this case, we believe that seasonal affective disorder led to the loss of the patient’s job, her husband, and finally her home.
2. Seasonal affective disorder is underdiagnosed. Despite describing a classic history for seasonal affective disorder and attending several hospital-based psychiatric clinics, our patient was diagnosed with nonseasonal major depression and was treated with antidepressants rather than light therapy. This resulted in a poor response to treatment; it is generally recognized that light therapy is a more effective treatment than medication for winter depression.
3. Medicaid’s policy is clinically and economically wrong for not covering light therapy. A light box costs approximately $200 and will provide treatment for many years. Our patient could not afford the $200 and would not have received the treatment had we not loaned her our light box. New York State Medicaid did pay for her antidepressants—fluoxetine and venlafaxine—which gave minimal relief and cost Medicaid approximately $200 per month ($164 per month for fluoxetine, 40 mg/day, and $212 per month for venlafaxine, 375 mg/day). Thus, Medicaid spent approximately $200 a month to provide an inferior treatment when this same $200 could have provided a light box for a universally accepted preferred treatment modality that would have assisted our patient not just for 1 month but for many years. Medicaid needs to finally "see the light" by including light therapy in its treatment formulary.