Employer-based health insurance is the major means by which we pay for
health care in America.
For years APA has been a leader, through its Business Initiative and the
American Psychiatric Foundation's Partnership for Workplace Mental Health, in
working with employers to alert them to the morbidity associated with
untreated mental illness in the workplace, particularly depression.
The economic losses associated with absenteeism and with reduced
productivity of depressed employees have led many employers to advocate for
better insurance coverage and incentives for the treatment of depression.
Based in part on pressure from employers, the Aetna Company, one of the
world's largest insurance companies, has decided to pay increased fees for
primary care physicians to screen patients for depression and to provide
follow-up care for patients who are then started on anti-depressant
In this program, severely depressed patients may be referred by the primary
care physician to a psychiatrist for care. The depression screening involves a
written test and the Patient Health Questionnaire (PHQ-9), which was developed
at Columbia University and tested in a variety of settings. Physicians
participating in the Aetna program are in six states and will be paid 30
percent to 40 percent more for a routine visit when the depression screening
questionnaire is used.
Since family physicians and other primary care doctors write an estimated
two-thirds of prescriptions for antidepressants in the United States and are
often the gate-keepers for referral to psychiatrists and mental health
professionals, this Aetna program, which will be carefully evaluated, is an
important breakthrough in providing financial support for depression
treatment. With nearly half of lost productivity in the United States
attributed to major depression, with an estimated cost of $44 billion
annually, this Aetna program will be carefully reviewed by other major payers,
HMOs, and employer groups, as well as professional organizations such as APA.
(To learn more about how APA is working to improve quality by working with the
business community, see Viewpoints column by Norman Clemens, M.D., on
Of course, any such study of treatment costs or savings cannot lose sight
of the key concern, which is making sure that each patient gets the depression
treatment that is best for him or her. Antidepressants are often seen as the
first-line treatment, as they are in the Aetna program. However, many
well-designed studies show that psychotherapy, especially cognitive-behavioral
therapy, is also beneficial for patients with depression and that cognitive
therapy is as effective as antidepressant medication for milder depression. A
study by Robert DeRubeis, Ph.D., and colleagues in the April 4, 2005,
Archives of General Psychiatry showed that cognitive therapy can be
as effective as medication for initial treatment of moderate to severe
depression, although cognitive therapy requires a high level of therapist
The APA practice guideline for treatment of depression emphasizes that the
choice of treatment depends on patient preference and the specialized skills
of clinicians. The presence of significant psychosocial stressors,
intrapsychic conflict, interpersonal difficulties, or comorbid Axis II
conditions indicate a need for psychotherapy as well as medication
Why are economic incentives encouraging depression treatment so important?
We know that, depending on the study, only between 5 percent and 40 percent of
depressed patients seen in primary care receive appropriate treatment and
follow-up. In the U.S. comorbidity study, only one-third of people with
depression received any care at all. According to burden-of-illness studies,
by 2020 depression will be the leading cause of disability worldwide.
APA is working to improve the quality of depression treatment across health
care settings through projects such as the National Depression Management
Leadership Initiative of the American Psychiatric Institute for Research and
Education—a collaboration between APA, the American Academy of Family
Physicians, and the American College of Physicians—to increase the
availability and quality of depression care through standardized use of the
PHQ-9 (Psychiatric News, June 3, 2005).
Other efforts include the APA Business Initiative's partnership with the
Kansas City employer coalition on the Community Initiative on Depression,
which leveraged the business community to address care for depression
delivered not only in primary care settings, but oncology and cardiology as
well (Psychiatric News, May 6, 2005).
The Aetna program is a leader in turning a spotlight on effective and early
diagnosis and treatment for this major medical/psychiatric condition. You can
be sure that APA will study the results of this initiative with great