More Workers Getting Treatment For Depression, but It’s Inadequate

The economic burden of depression remained relatively stable in the 1990s, despite a dramatic increase in the proportion of people with depression being treated.

A 10-year study on the economic burden of depression appearing in the January Journal of Clinical Psychiatry found that the annual cost of depression (including major depression, bipolar disorder, and dysthymia) rose just 7 percent in inflation-adjusted dollars between 1990 and 2000, despite a more than 50 percent increase in the number of people being treated for the condition.

Of the $83.1 billion spent in 2000 on the treatment of depression and related expenses, $26.1 billion (31 percent) were direct medical costs, $5.4 billion (7 percent) were suicide-related mortality costs, and $51.5 billion (62 percent) were workplace costs.

But study author Ronald Kessler, Ph.D., believes that behind the good news about stable costs and increasing treatment numbers is a less-encouraging story of substandard care.

“It’s striking that we have known for a couple of years now that the number of people in treatment for depression has gone up, and you would expect that the cost of treatment would have skyrocketed,” Kessler, an epidemiologist at Harvard Medical School, told Psychiatric News. “But once you get inside the numbers, the news is not so good. Many more people are getting pharmacotherapy from a primary care physician, but they may not be getting it at the adequate dose or for the appropriate amount of time.”

Kessler, a professor of health care policy at Harvard Medical School, said he believes much of the increase in numbers of people being treated is driven by patients who seek out medication from a primary care doctor, but who are very liable to stop taking medication as soon as they begin to feel better.

“These people are much more likely to take a pill for 15 days or 30 days and then drop out of treatment when they feel a little bit better,” Kessler said. “So, the downside of the increasing numbers of people being treated and the cost of staying stable is that we are spending a lot of dollars on people who are not getting adequate treatmentHe added that he believes better coordination of care between primary care and psychiatrists and mental health specialists is the key to cost-effective, high-quality care.”

Paul Greenberg, M.A., M.B.A., who co-wrote the report with Kessler, told Psychiatric News the study found much of the treatment of depression had shifted from inpatient to outpatient—specifically, primary care—settings.

“This is not going to come as a surprise to psychiatrists,” he said. “In 1990 about two-thirds of direct medical costs were hospital days. By 2000 inpatient care accounted for only a third of direct medical costs.”

Greenberg is managing principal at Analysis Group, an economic, financial, and strategy consulting firm with offices throughout the United States and Canada.

Kessler and Greenberg used a human capital approach—an analytical tool used to measure an individual’s productive capacity—to develop prevalence-based estimates of direct costs of depression, mortality costs arising from depression-related suicides, and costs associated with depression in the workplace.

Among the study’s most striking findings is the persistence of the workplace as the site where depression exacts its highest economic toll.

“The majority of costs still show up in the workplace in the form of reduced capacity to work,” Greenberg told Psychiatric News. “These are people who show up for work but can’t work at their usual level of performance, as well as people who cannot show up for work at all. So absenteeism and ‘presenteeism’ continue to be economic factors in the cost of depression.

“Clearly, the activities of daily living for a depressed person are dramatically adversely affected,” Greenberg said.

And he noted also an important implication of the study findings: as economic conditions improve, more people are employed and covered by health insurance and therefore more likely to be treated when they are depressed. Conversely, in a sluggish economy fewer people will be employed and able to access care.

Kessler echoed the importance of the cost of depression in the workplace, citing it as an area of immense opportunity.

“There is an entire burgeoning area of literature that looks at the impact of medical conditions on role performance,” Kessler said. “Depression is one of the most costly conditions in the workplace, and the majority of dollars for health care comes from employers. They are very interested in knowing what they are getting for their dollar. Where once mental health was likely to be the first thing cut, today a lot of forward thinking employers are seeing the value of high-quality mental health care.” ▪