Without significant changes in the U.S. health care system, baby boomers
who experience depression in the coming years will likely face increased
barriers in access to, and quality of, mental health care, new research has
Today the vast majority of elderly patients with depression receive care in
primary-care settings under Medicare. They have limited access to
comprehensive psychiatric care because of Medicare's discriminatory 50 percent
copayment for mental health services. Now, with the debut of the new Medicare
Part D drug benefit only months away, some researchers believe that many of
these patients will greatly expand the number of people already treated for
depression with medications only, without the benefit of appropriate
comprehensive care, including psychotherapy.
"Undoubtedly, what you are going to see with Part D is even more
undermanaged, drug-only treatment," predicted Stephen Crystal, Ph.D., a
research professor at the Rutgers University School of Social Work and chair
of the Division on Aging at Rutgers Institute for Health, Health Care Policy,
and Aging Research.
"What we see now is 20 to 25 percent of the elderly depressed
population who lack prescription drug coverage, and another 20 percent who
have minimal coverage. With Part D, you'll have increased use of
antidepressants, without a doubt. And because availability drives
diagnosis—rather than the other way around—you'll see even more
patients being diagnosed with depression simply because the drug treatment is
Moreover, Crystal told Psychiatric News, he expects the quality of
care to be substandard.
"There's no way psychiatry [as a field] can keep up with providing
services to all those people who will be diagnosed, especially in nonurban
areas," Crystal predicted. The result could be an impending
Crystal based his observations on research he and colleagues at Rutgers
recently completed on the use of psychotherapy for depression in elderly
patients covered by Medicare. Their report appeared in the April American
Journal of Psychiatry. The study was funded by grants from the National
Institute of Mental Health, the National Institute on Aging, and the Agency
for Healthcare Research and Quality.
Crystal and his colleagues noted that several types of psychotherapy have
been shown to be effective in treating the elderly for depression. While
pharmacotherapy is considered a mainstay of treatment, many experts have
raised concerns recently regarding the effectiveness of antidepressants in
elderly patients, particularly since drug-drug interactions and adverse
effects can be significant in this population.
Although Agency for Health Care Policy and Research guidelines recommend
treatment for four to nine months in older patients with depression to reduce
the likelihood of recurrence, the extent that psychotherapy is used in such
treatment is unknown. Crystal examined national patterns in psychotherapy
treatment in elderly patients with depression by analyzing Medicare claims and
survey data from the 1992 through 1999 Medicare Current Beneficiary Survey
cost and utilization files.
A lot of the treatment for depression, Crystal said, "is very
superficial, not very well managed. The great bulk of it is done in the
primary care sector in 10- or 20-minute encounters where there's usually a
whole series of issues that must be dealt with."
As a result, he continued, depression gets short shrift. Primary care
providers seldom use structured instruments to screen for the disorder or
evaluate response to treatment, he added.
What Crystal and his colleagues found did not surprise them, he said."
There's a minority—only about a quarter of elderly patients
diagnosed with depression—who are getting any psychotherapy, and most of
that therapy is very brief," he noted. "The thing that jumped out
though, in addition to the low treatment rate, were socioeconomic
Patients who were under age 80, had higher education levels, and lived in
urban areas were significantly more likely to receive psychotherapy."
The whole issue about rural mental health care is huge; the services
simply are not there."
To understand the trends, Crystal said, "you really have to look at
what has happened to psychiatry in the past 10 to 15 years." With
managed care in general, the emphasis has been increasingly shifted toward
With respect to the elderly population, Crystal added, "I have to
think it has even more to do with the limitations on supply [of geriatric
psychiatrists] and to the very substantial financial limitations. How many
patients can afford a 50-percent copayment [required by Medicare]?"
Another significant barrier facing elderly patients with depression,
Crystal said, is that Medicare may only reimburse psychiatric consultations
for patients in primary care settings at 50 percent.
"This is something that Medicare is going to have to look at,"
Crystal continued. "There are never going to be enough psychiatrists and
certainly not going to be enough geriatric psychiatrists to care for all these
Nonetheless, as the brunt of the mental health care has fallen to primary
care physicians, efforts have aimed at building effective models of primary
care—based depression treatment, Crystal acknowledged.
One such model is NIMH's Project IMPACT, which uses depression care
managers—typically nurse practitioners or social workers—within
primary care practices (Psychiatric News, April 4). However, these
models remain problematic, he said.
"I don't agree with the trend that depression has become a primary
care disease that doesn't really need specialist treatment," Crystal
said. "I'm not sure our psychopharmacology is analogous" to other
treatments once the domain of specialists, such as treating ulcer disease or
reflux and uncomplicated cardiovascular disorders. "The advances [in
psychopharmacology] aren't so definitive that it makes the `trickle-down'
analogy as clinically rational as it might be for some other
Crystal noted that many elderly depression patients do not respond well to
antidepressant pharmacotherapy, especially those with recurrent depression.
Yet the discriminatory 50 percent copayment makes psychotherapy a costly
"The statutory discrimination inherent in Medicare has no evidence
base—it is simply a cost-containment vehicle," Crystal said. With
new drug coverage under Medicare Part D, this will only be exaggerated, he
Cost-effectiveness, rather than simply cost, should weigh heavily in
Medicare coverage decisions, Crystal concluded. As it does for children,
adolescents, and nonelderly adults, research suggests that combining
medication with psychotherapy improves depression treatment outcomes in the
"We need to look at cost-effectiveness, head to head, with some other
highly expensive services that we provide for elderly patients," Crystal
offered, "and it may be that some other specialty treatments should have
a 50 percent copayment before you require it of psychotherapy."
An abstract of "Use of Psychotherapy for Depression in Older
Adults" is posted online at<http://ajp.psychiatryonline.org/cgi/content/abstract/162/4/711>.▪
Am J Psychiatry