Americans More Willing To Seek Out Treatment

A surge in outpatient treatment for depression over the past decade has led experts to speculate that education programs about mental illness and antistigma campaigns coinciding with improved treatments have begun to pay off.

Between 1987 and 1997, researchers found that the rates for outpatient treatment of depression more than tripled. In 1987, 0.7 percent of the American population, or 1.76 million people, received outpatient treatment for depression. A decade later, this percentage jumped to 2.3 percent, or 6.33 million people.

In addition, of those treated for depression, 44.6 percent were prescribed a psychotropic medication in 1987, compared with 79.4 percent in 1997.

These data were published in a report appearing in the January 9 Journal of the American Medical Association by Mark Olfson, M.D., M.P.H., and colleagues. Olfson is an associate professor of clinical psychiatry at Columbia University and the New York State Psychiatric Institute.

Olfson collected data from two surveys sponsored by the federal Agency for Healthcare Research and Quality—the 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey. In both surveys, respondents were asked to record medical “events,” such as visits to a physician, in a diary. The events were later discussed during face-to-face interviews with survey researchers.

Tens of thousands of households in the U.S. were polled for the surveys, and the data were used to determine health care utilization and sources of payments, among other things.

The researchers found an overall increase in the number of Americans who received psychotherapy for treatment of their depression over the decade under study. In 1987, 1.25 million people (.52 percent) received psychotherapy for depression compared with 3.8 million people (1.4 percent) in 1997. What is notable, however, is that the percentage of those who received psychotherapy (which included mental health counseling) declined from 71 percent to 60 percent.

Treatment was characterized by greater involvement of physicians, although the physician’s specialty was not specified by the study. Almost 69 percent of people in treatment for depression visited a physician to get this treatment in 1987, increasing to 87.3 percent in 1997.

Harold Pincus, M.D., the executive vice chair of psychiatry at the University of Pittsburgh and co-author of the study, said that although the growth in treatment for depression is good news overall, the quality of this treatment is still in question.

“We don’t know if these cases are longitudinal contacts—whether people are being treated over the long term effectively,” said Pincus, who is also director of the RAND Corporation’s health program in Pittsburgh and former director of APA’s Office of Research.

He noted that primary care doctors are probably handling the bulk of the depression cases.

Pincus noted that the study arose out of a national program sponsored by the Robert Wood Johnson Foundation called Depression in Primary Care: Linking Clinical and System Strategies (Psychiatric News, September 7, 2001).

“In this program, we are trying to break down some of the barriers to effective depression treatment in primary care,” said Pincus, who directs the program.

What is behind this dramatic shift in the number of people seeking help for depression? “The availability of antidepressant medications with fewer distressing side effects commonly weighs in on the decision to seek treatment,” said Olfson, referring to the introduction of fluoxetine in late 1987. This drug was followed by the development of other selective serotonin reuptake inhibitors (SSRIs), which boasted fewer harmful and bothersome side effects and which posed less danger of overdose than the older tricyclic antidepressants previously used to combat depression.

Depression Awareness

Olfson and his co-authors also noted that antistigma and education campaigns directed at the health care industry and the public made it easier for people to seek help for depression.

One such major public health and antistigma campaign noted by the study authors was the National Institute of Mental Health’s Depression, Awareness, Recognition, and Treatment (DART) program, launched in 1988.

The program targeted three groups for depression education: primary care clinicians, mental health clinicians, and the general public. It sought to increase knowledge of the symptoms of depression and the availability of effective treatments.

Darrel Regier, M.D., M.P.H., executive director of the American Psychiatric Institute for Research and Education, served as director of the Division of Clinical Research for the DART program. He told Psychiatric News that the program sponsored public service announcements, awards presentations, and celebrity appearances that included actor Rod Steiger, humorist Art Buchwald, and the Harlem Globetrotters, for instance. DART was folded into a depression outreach program at NIMH in the mid-1990s.

In addition, an article published by Regier and colleagues in the November 1988 issue of the American Journal of Psychiatry established the scientific basis for the treatment of depression and lent extra credibility to the education and antistigma efforts of the DART program.

The article showed that depression is a treatable and common condition, and that most people seeking help for depression turn to their primary care doctors first.

Another well-known public education program of the early 1990s seeking to raise awareness of depression was the National Mental Health Association’s Campaign for America’s Mental Health, which was sponsored by Eli Lilly and Co. It was begun in 1992.

Study authors also noted the widespread influence of National Depression Screening Day (NDSD), first launched in 1991 and conducted by Screening for Mental Health Inc. By the end of the second data collection in 1997, NDSD had established 2,800 screening sites in the U.S. and Canada, according to the report.

Olfson and his colleagues linked these national depression education and antistigma programs to increased public acceptance of medication intervention, as reflected in opinion polls.

For instance, findings from a 1986 Roper poll showed that only 12 percent of respondents were willing to take medication for depression and that 78 percent of people would be willing to live with the depression until it passed. An ABC News poll conducted in April 2000, however, found that 28 percent of adults would be “willing to take antidepressants for depression over an extended period even though they were informed that safety studies had not been conducted on long-term use of these medications.”

Long Road Ahead

Paul J. Fink, M.D., a former APA president and currently chair of APA’s Task Force on Psychiatric Aspects of Violence, has long been involved with protecting patients’ rights and the destigmatization of mental illness for years. He maintained a cautionary perspective of the study findings.

“I think the increase in people being treated for depression is fabulous,” Fink said. “However, there are still millions of people who are afraid to seek treatment for depression and other mental illnesses due to stigma.” These people, he noted, may quit treatment and stop taking medications prescribed to them because “they are afraid to be on a mind-altering drug, even if this drug could save their lives.”

Although the study results are good news, “psychiatrists should not be complacent,” warned Fink, who said that so much stigma still surrounds mental illness that it is hard to measure.

One reason to stay vigilant is to guard against future stigma, according to Fink. “New generations of people are seriously and negatively affected by all of the antipsychiatry hype, which makes it harder and harder to sustain the concept that there is value in what we [as psychiatrists] do.”

Future antistigma efforts should continue to guide people to depression screening, evaluation, and high-quality treatment. “Good treatment is destigmatizing,” said Fink, “and with it, people with depression can live good lives.”

An abstract of the study, “National Trends in the Outpatient Treatment of Depression,” is posted on the Web at http://jama.ama-assn.org/issues/v287n2/abs/joc11356.html. ▪

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